DANMAP 2001
DANMAP
2001
DANMAP 2001 - Use of antimicrobial agents and
occurrence of antimicrobial resistance in bacteria from
food animals, foods and humans in Denmark
Statens Serum Institut
Danish Veterinary and Food Administration
Danish Medicines Agency
Danish Veterinary Institute
DANMAP 2001
_
Editors:
Flemming Bager
Hanne-Dorthe Emborg
Ole Eske Heuer
Danish Zoonosis Centre
Danish Veterinary Institute
Bülowsvej 27
DK - 1790 Copenhagen V
DANMAP board:
Danish Veterinary Institute:
Flemming Bager
Henrik C. Wegener
Frank Aarestrup
Danish Veterinary and Food
Administration:
Bodil Lund Jacobsen
Jeppe Boel
Statens Serum Institut:
Dominique L. Monnet
Thomas Lund Sørensen
Peter Gerner-Smidt
Niels Frimodt-Møller
Danish Medicines Agency:
Lasse Larsen
Layout:
Susanne Carlsson
Danish Zoonosis Centre
Printing: Datagraf Auning A/S
DANMAP 2001 - July 2002
ISSN 1600-2032
Text and tables may be cited and reprinted only
with reference to this report.
Reprints can be ordered from:
Danish Veterinary Institute
Bülowsvej 27
DK - 1790 Copenhagen V
Phone: +45 35 30 01 48
Fax:
+45 35 30 01 20
e-mail: [email protected]
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3
Contents
Contributors to the 2001
DANMAP Report
4
Acknowledgements
5
Note to readers
5
Sammendrag
6
Summary
8
Demographic data
10
Antimicrobial use
11
Resistance in zoonotic bacteria
25
Ø
Ø
25
31
Salmonella
Campylobacter
Resistance in indicator bacteria
34
Ø
Ø
34
41
Enterococci
Escherichia coli
The report is also available from the Zoonosis
Centre homepage: http://www.vetinst.dk
This publication is issued by
DANMAP - The Danish Integrated
Antimicrobial Resistance Monitoring
and Research Programme. It
presents the results of antimicrobial
use and resistance monitoring in food
animals, foods and humans in 2001
and is produced in collaboration
between the Danish Veterinary
Institute, the Danish Veterinary and
Food Administration, the Danish
Medicines Agency and Statens
Serum Institut. The DANMAP programme is funded jointly by the
Ministry of Food, Agriculture and
Fisheries and the Ministry of Health.
Resistance in bacteria from
diagnostic submissions
45
Ø
Ø
45
49
Bacteria from animals
Bacteria from humans
Appendix 1
Materials and methods
54
Appendix 2
DANMAP Publications
62
Appendix 3
Results for food isolates from 2000
66
4
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The DANMAP 2001 was written
by the following persons:
Flemming Bager
Hanne-Dorthe Emborg
Ole Eske Heuer
Danish Zoonosis Centre
Danish Veterinary Institute
Bülowsvej 27
DK - 1790 Copenhagen V
Dominique L. Monnet
Hans Ulrik Kjærem Nielsen
Statens Serum Institut
Artillerivej 5
DK - 2300 Copenhagen S
Sigrid Andersen
Danish Veterinary and Food
Administration
Mørkhøj Bygade 19
DK - 2860 Søborg
The following persons were
involved in providing data for
the report:
Danish Veterinary Institute:
Karl Pedersen
Jens Christian Østergaard Jørgensen
Alice Wedderkopp
Eva Haarup Sørensen
Kirsten Christensen
Erik Jacobsen
Vibeke Frøkjær Jensen
Frank Møller Aarestrup
Anne Mette Seyfarth
Anne Petersen
Eva Møller Nielsen
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DANMAP 2001
Danish Veterinary and Food Administration:
Rikke Kubert
Dorthe Laugesen
Anne Arvelund Olsen
Peter Saadbye
Sigrid Andersen
Jeppe Boel
Katrine Lundsby
Amer Mujezinovic
Henrik Ottosen
Kai Vest
Thomas Kvist
Winnie Grebell
Kate Vibefeldt
H:S Hvidovre Hospital:
Henrik Westh
Bettina Lundgren
Elly K. Kristensen
Statens Serum Institut:
Maiken Arendrup
Anette Arndt
Kristiane B. Beicher
Christian Brandt
Jens Jørgen Christensen
Jørgen Engberg
Steen Ethelberg
Alice Grassy
Ingrid B. Jensen
Elsebeth T. Jensen
Ole Bent Jepsen
Annemarie Jørgensen
Margit Kaltoft
Thomas Klemmensen
Helle B. Konradsen
Lena Lisbeth Mejlby
Jette Mondrup
Robert Skov
Christina Zinn
Herning Hospital:
Steen S. Schrøder
Herlev Hospital:
Jens Otto Jarløv
Slagelse Hospital:
Henrik M. Friis
Næstved Hospital:
Hans Erik Busk
Esbjerg Hospital:
Kjeld Truberg Jensen
Aarhus Municipality Hospital:
Jens K. Møller
Viborg Hospital:
Helga Schumacher
Jørgen Prag
Birgitte Tønning
Aalborg Hospital:
Henrik C. Schønheyder
Lena Mortensen
Tinna R. Urth
Danish Medicines Agency:
Karin Hovgaard
Suggested citation:
DANMAP 2001. Use of antimicrobial agents and occurrence of antimicrobial resistance in bacteria from food
animals, foods and humans in Denmark. ISSN 1600-2032.
DANMAP 2001
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Acknowledgements
The Danish Veterinary Institute would like to thank the
meat inspection staff and the company personnel for
collecting samples from animals at slaughter. Without
their careful recording of the animals’ farm of origin the
results would be much less useful. We are also very
grateful to the Cattle Health Laboratory at Ladelund and
the Laboratory of the Danish Pig Producers and
Slaughterhouses for making isolates of animal
pathogens available to the programme.
The Danish Veterinary and Food Administration would
like to acknowledge the assistance of the staff of the 11
Regional Veterinary and Food Control Authorities.
Statens Serum Institut would like to thank the Danish
Medicines Agency for providing data on consumption of
antimicrobials in humans, and the clinical microbiology
laboratories for providing data on resistance in bacteria
from human clinical samples.
Note to readers
In producing the DANMAP reports we have attempted to
provide as much information as possible in the space
available. Our written commentary is an attempt to draw
attention to trends that we find particularly interesting or
to provide additional information pertinent to the interpretation of trends in usage of antimicrobials or in
resistance.
This year we have decided to present the MIC distributions for all combinations of bacteria and antimicrobials
tested, in addition to the percentage resistant with the
appropriate confidence interval. We also included text
boxes describing results of antimicrobial residue
monitoring as well as a description of veterinary
antimicrobial treatment guidelines.
We have highlighted certain trends by illustrating them
graphically. The reader will be able to graph other trends
by obtaining data from previous years reports. Sufficient
data have also been made available to allow the reader
to calculate whether differences from one year to the
next are statistically significant. Previous DANMAP
reports maybe downloaded from the Zoonosis Centre
website at: http://www.vetinst.dk.
DANMAP 2001 presents, for the first time, usage data
collected by the VetStat programme launched in year
2000. While usage data until now have been collected
from the pharmaceutical companies, VetStat data are
collected much closer to the point of use, and includes
information about target animal species and age group.
We have found a discrepancy between usage data from
VetStat and reporting from the pharmaceutical industry.
This is described in the section about antimicrobial
usage and VetStat data collection system in Text box 1.
For technical reasons, data on resistance in bacteria
from food were not included in the report for 2000. They
may be found in Appendix 3 of the present report.
6
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DANMAP 2001
Sammendrag
DANMAP 2001 er den 6. rapport fra det danske program til overvågning af antibiotikaresistens og
antibiotikaforbrug. I år præsenterer vi for første gang
antibiotikaforbruget fordelt på dyreart og aldersgruppe,
ligesom resultaterne af resistensbestemmelse er vist
som MIC-fordelinger, foruden som grafiske fremstillinger
af resistensudviklingen.
Forbrug af antibiotika
DANMAP giver en samlet fremstilling af anvendelsen af
antibiotika til dyr såvel som til mennesker. Hvad angår
mennesker er alle oplysninger om forbrug af receptpligtig
medicin hos hver enkelt patient blevet indsamlet af
Lægemiddelstyrelsen siden begyndelsen af 1990’erne.
Lægemiddelstyrelsen har bidraget med data til denne og
tidligere DANMAP rapporter. I 2000 blev det landsdækkende register for receptpligtig veterinærmedicin,
VetStat, taget i brug. VetStat giver oplysninger om
forbruget af medicin på besætningsniveau, herunder
forbruget til de enkelte husdyrarter og aldersgrupper.
Fremtidigt vil VetStat opgørelser erstatte de
indrapporteringer fra medicinalindustrien, som hidtil har
udgjort grundlaget for analyser af forbrugsudviklingen. En
sammenligning af de to kilder til forbrugsoplysninger
tyder på, at VetStat tegner et mere præcist billede af det
totale forbrug end det er tilfældet med indberetningerne
fra toppen af distributionskæden.
Forbrug til dyr. Brugen af antibiotiske vækstfremmere
blev udfaset i 1999 og det samlede forbrug af antibiotika
til dyr er faldet fra 205 tons aktivt stof i 1994 til mindre
end 100 tons i 2001. Brug af antibiotika til behandling af
dyr er imidlertid steget i de senere år. Stigningen er
særligt på den gruppe antibiotika, der bruges til medicinering gennem foder og drikkevand. Stigningstakten fra
2000 til 2001 var dog mindre (20%) end i det foregående år (62%). Samlet er forbruget af antibiotika til
produktionsdyr steget med 17% (Tabel 3). I de foregående års rapporter har vi formodet, at den væsentligste
del af forbruget af antibiotika blev brugt til smågrise.
Oplysningerne fra VetStat har bekræftet dette. Svin
tegner sig for 71,2 ton (74%) af det samlede forbrug på
96,2 ton og 41% af al antibiotika til svin blev brugt til
smågrise (Tabel 4 og 5). Ved hjælp af VetStat har vi
kunnet opgøre forbruget som daglige doser (Animal
Daily Dosages, ADD). Denne opgørelse vises i Tabel 6. I
2001 blev der brugt 152 millioner antibiotikadoser til
22,9 millioner smågrise, svarende til 6,6 ADD til hver
smågris. Til sammenligning blev brugt 1,6 ADD til
slagtesvin, dvs. svin over 35 kg. Til sammenligning blev
der i slagtekyllingeproduktionen kun brugt 0,4 ADD til
hver kylling, der blev produceret. Langt det højeste
forbrug var dog i dambrug, hvor der blev brugt hvad der
svarer til 79 mg antibiotikum pr. kg. fisk produceret. Til
sammenligning blev der i svineproduktionen brugt hvad
der svarer til 41 mg antibiotika pr. kg. produceret
svinekød.
Som tidligere nævnt er de antibiotiske vækstfremmere
blevet udfaset i Danmark, og det totale forbrug i 2001
var på 14 kg. som fortrinsvis udgjordes af flavomycin.
Forbrug til mennesker. Udskrivning af medicin i almen
praksis steg med 5% i 2001. Stigningen lå overvejende
på gruppen af penicilliner. Analyser har ikke med
sikkerhed kunnet afsløre årsagen til stigningen, men
resultaterne tyder på, at den kan skyldes en meningitis
epidemi i februar og marts 2001 og de deraf følgende
bekymringer for spredning af smitten.
Resistens hos zoonotiske bakterier
I sidste års DANMAP rapport beskrev vi, hvorledes
spredning af en nalidixansyre resistent klon af Salmonella Enteritidis hos fjerkræ havde en stor betydning for
den samlede forekomst af kinolonresistens hos S.
Enteritidis i 2000. I 2001 blev klonen ikke påvist, sandsynligvis som resultat af den generelle salmonellabekæmpelse i ægproduktionen. Status i 2001 var, at
kinolonresistens hos S. Enteritidis og S. Typhimurium
fra produktionsdyr stort set var fraværende (Tabel 15 og
16). Kinolonresistens blev kun fundet hos svin, hvor to S.
Typhimurium isolater var resistente overfor nalidixansyre
og tillige havde nedsat følsomhed for fluorokinoloner.
Ingen isolater var resistente overfor cephalosporiner.
Blandt S. Typhimurium fra mennesker har der været
stigende resistensforekomst i de senere år, særligt
blandt isolater fra salmonellainfektioner erhvervet i
udlandet (Figur 7). Resistens blandt hjemligt erhvervede
S. Typhimurium tilfælde hos mennesker er generelt
højere end blandt isolaterne fra produktionsdyr. Det
skyldes blandt andet smitte fra importerede fødevarer,
ligesom der kan være en underrapportering af infektioner, der er erhvervet i udlandet. Svin er årsag til mellem
4,8 og 6,4% af Salmonella infektioner hos mennesker,
herunder især infektioner med S. Typhimurium. Siden
1999 synes en stigende forekomst af tetracyklinresistens hos S. Typhimurium fra svin at afspejles i en
stigning hos mennesker, hvor tetracyklinresistens nåede
31% blandt hjemligt erhvervede infektioner med S.
Typhimurium tilhørende andre fagtyper end DT104
(Tabel 23).
For Campylobacter har vi i lighed med foregående år
set, at forekomsten af kinolonresistens tilsyneladende
DANMAP 2001
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afspejler brugen af fluorokinoloner. Blandt
Campylobacter jejuni fra slagtekyllinger er der stigende
forekomst af kinolonresistens, medens det falder hos C.
coli fra svin. I 2001 svarede fluorokinolonforbruget til
slagtekyllinger til 2,6 mio. ADD givet som oral medicinering, sammenlignet med mindre end en million til svin
givet som injektion. Forbruget til svin har været faldende
siden et fluorokinolon til fodermedicinering blev taget af
markedet i 1999. Der er en tilsyneladende forskel i
resistensforekomst og udviklingstendens hos C. jejuni
fra mennesker og fra kyllinger (Figur 8). Epidemiologiske undersøgelser har vist, at kyllinger er en vigtig kilde
til smitte af mennesker i Danmark. Hos mennesker er
der højere resistensforekomst blandt Campylobacter
isolater, der stammer fra personer der har været på
rejse i udlandet (Tabel 27), og det er muligt at den
nævnte forskel delvis kan forklares ved at en del rejseassocierede tilfælde fejlagtigt registreres som værende
smittet i Danmark. Dertil kommer tilfælde som er smittet
i Danmark fra importerede fødevarer.
Resistens hos indikatorbakterier
I DANMAP 2000 beskrev vi, hvorledes en multiresistent
Enterococcus faecium klon havde stor indflydelse på
det samlede resistesniveau hos svin og kvæg. Denne
klon var stadig til stede i 2001, men forekomsten var
lavere end i 2000. Overordnet var der en god sammenhæng mellem udfasning af brugen af antibiotiske
vækstfremmere og resistensudviklingen hos E. faecium
fra slagtekyllinger og svin, henholdsvis fra kyllingekød og
svinekød (Figur 10-15). Den tilsyneladende dårlige
overensstemmelse mellem forekomst af visse resistensfænotyper fra produktionsdyr og prøver af kød herfra
udtaget i detailleddet skyldes delvis tilfældige variationer
på grund af det begrænsede bakterieisolater fra visse
fødevarekategorier. Imidlertid er enterokokker i stand til
at overleve og formere sig i miljøet i produktionslokaler,
som det fremgår af vore fund af enterokokker i fisk i
tidligere års DANMAP undersøgelser. Det er derfor
muligt, at enterokokker i fødevarer kun delvis afspejler
enterokokpopulationerne i de dyr, de pågældende
fødevarer stammer fra.
Derimod er der for Escherichia coli fra slagtedyr god
overensstemmelse med resistensniveauet i de tilsvarende produktkategorier. Generelt er resistensforekomsten lav, lavere end i importerede fødevarer. Ca.
10% af isolaterne fra kyllinger og kyllingekød var resistente overfor nalidixansyre og et enkelt isolat fra
kyllingekød af dansk oprindelse var resistent overfor
ciprofloxacin. Ingen af isolaterne var resistente overfor
cephalosporiner.
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I 2002 er der som led i DANMAP overvågningen etableret indsamling af prøver fra raske mennesker med
henblik på at overvåge resistensudviklingen hos E. coli
og enterokokker. Resultaterne vil blive beskrevet i
fremtidige DANMAP rapporter.
Resistens i prøver fra diagnostiske indsendelser
Produktionsdyr. En sammenligning af resistensresultater for E. coli fra diagnostiske indsendelser (Tabel
37) med resultaterne fra indikator E. coli viser, at
forekomsten er højest blandt førstnævnte. Medens
niveauet blandt E. coli fra slagtekyllinger generelt er
faldende eller uændret (Figur 17) giver andre af
udviklingstendenserne årsag til bekymring. Således har
kinolonresistens blandt E. coli fra kvæg været næsten
uafbrudt stigende siden 1996.
Blandt E. coli fra svin er tetracyklinresistens i stigning
medens kinolonresistens falder. Dette afspejler formentlig udviklingen af forbruget af de pågældende
antibiotikagrupper. I en tidligere DANMAP rapport
henledte vi opmærksomheden på, at markedsføring af
apramycin til behandling af infektioner hos svin og kalve
kunne føre til en stigning i resistens overfor gentamicin.
Dette forhold er den mulige årsag til den stigning i
gentamicinresistens vi har set hos E. coli fra svin og
kvæg fra 2000 til 2001, men det skal understreges at det
genetiske grundlag for resistensen endnu ikke er
undersøgt.
Der er et relativt lavt resistensniveau blandt stafylokokker fra mastitis hos kvæg, herunder resistens overfor
penicillin. Ingen isolater var resistente overfor
cephalosporiner. For Staphylococcus hyicus fra svin
gælder at resistenstendenserne er noget variable (Figur
18). Dette kan delvis forklares ved at antallet af isolater
er begrænset. Derudover kender vi ikke årsagen hertil.
Mennesker. DANMAP giver en samlet fremstilling af
resistensoplysninger for nogle almindeligt forekommende sygdomsfremkaldende bakterier fra mennesker.
Elleve ud af 16 amter bidrager nu med resultater. Om
end det synes klart at udviklingen overordnet set er
meget sammenlignelig i alle egne af landet, betyder
forskelle i overvågningsmetoder i de enkelte amter dog,
at det ikke er muligt at kombinere resultaterne med
henblik på detaljerede analyser af udviklingen i relation
til antibiotikaforbruget.
I DANMAP 2000 kommenterede vi udvikling i
methicillinresistens hos Staphylococcus aureus. Udvikling i methicillinresistens fortsatte med at stige i 2001 og
om end forekomsten stadig er lav, er der dog grund til at
følge udviklingen nøje.
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DANMAP 2001
Summary
DANMAP 2001 is the 6 th report from the Danish Integrated Antimicrobial Resistance Monitoring and Research Programme. This year we present data on
antimicrobial usage by animal species and age group
and the susceptibility data – in addition to resistance
trends – are shown as MIC distributions.
Antimicrobial use
DANMAP brings together data on the use of
antimicrobials in animals and in humans. Since the early
1990’s, usage of all prescription medicines in humans
has been monitored at the level of the individual patient.
This monitoring has been carried out by the Danish
Medicines Agency who has provided data for the usage
trends in this and in previous DANMAP reports. In 2000,
we initiated a prescription-based monitoring of medicine
usage in animals. This programme, VetStat, provides
information about usage at herd level, including target
animal species and age group. Data from this programme will replace reporting by the pharmaceutical
industry of annual sales, the data that have until now
formed the basis for usage trends described in
DANMAP reports. A comparison of the two reporting
systems in this years report indicate that the VetStat
programme provides more accurate measures of total
usage than does reporting from the top of the distribution
pyramid.
Usage in animals. Antimicrobial growth promoters
were phased out in Denmark in 1999 and total
antimicrobial usage in food animals has been cut in half
from 205 tonnes of active compound in 1994 to less than
100 tonnes in 2001. Usage of antimicrobials for therapy
has increased in recent years and we saw a further
increase in the usage of antimicrobials for oral
application in 2001 compared with 2000, although the
rate of increase was slower (20%) than in the previous
year (62%). Overall usage of antimicrobials for treatment
of food animals, increased by 17% (Table 3). In previous
reports we have speculated that a significant part of the
total usage was in weaner pigs. The point-of-use data
provided by VetStat have been able to confirm this: pigs
account for 71.2 tonnes of a total of 96.2 tonnes of
antimicrobials used for animals in Denmark (74%) and
weaner pigs alone account for 41% of antimicrobials
used in that species (Tables 4 and 5). In the VetStat
system we have calculated usage as Animal Daily
Dosages (ADD’s). The results are presented in Table 6.
In 2001, 152 million ADD’s were used in 22.9 million
weaner pigs, or 6.6 ADD per weaner pig, compared with
1.6 ADD in slaughter pigs. In contrast to pigs, broilers
were given a more modest 0.4 ADD total antimicrobial
per bird produced. The highest usage, however, was in
aquaculture, with 79 mg antimicrobial per kg fish
produced. In comparison, usage in pigs amounted to 41
mg per kg pig slaughtered.
Antimicrobial growth promoters have been phased out in
Denmark and total usage in 2001 was 14 kg, mainly
flavomycin.
Consumption in humans. In human medicine,
consumption of antimicrobials in primary health care
increased by 5%, mainly as a result of an increased use
of beta-lactamase sensitive penicillins. Analyses
indicated that a possible explanation for the increased
consumption might be concerns sparked by an outbreak
of bacterial meningitis in February and March 2001.
Resistance in zoonotic bacteria
In our previous report we described how the spread of a
nalidixic acid resistant clone of Salmonella Enteritidis in
poultry had a significant effect on the overall level of
quinolone resistance in that bacterium in 2000. In 2001,
none of the isolates were resistant to nalidixic acid as a
result of the general measures to control Salmonella in
layers. Overall, we have found quinolone resistance in S.
Enteritidis and S. Typhimurium from food animals to be
almost absent (Tables 15 and 16). The only finding was
in pigs, where two isolates were resistant to nalidixic
acid and also had decreased susceptibility to
ciprofloxacin. Resistance to cephalosporins was absent
in Salmonella. Resistance among S. Typhimurium from
humans has been increasing in recent years, especially
in cases associated with foreign travel. (Figure 7).
Levels of resistance among domestically acquired
human S. Typhimurium show that the levels are generally
higher than among isolates from food animals. The main
reason for this is the contribution from imported food
stuffs and some underreporting of travel. Pigs are
recognized as the source of between 4.8% to 6.4% of
Salmonella infections in humans, in particular infections
with S. Typhimurium. Since 1999, increasing levels of
tetracycline resistance in S. Typhimurium from pigs
appear to be reflected in increases in humans, where
tetracycline resistance reached 31% in domestically
acquired infections with S. Typhimurium phage types
other than DT104 (Table 23).
In Campylobacter from food animals we have observed
as we did in 2000, that the level of quinolone resistance
appears to reflect usage: in C. jejuni from broilers
DANMAP 2001
_
resistance, is increasing, while it is decreasing in C. coli
from pigs. In 2001, fluoroquinolone usage in broilers
amounted to 2.6 million ADD’s as oral medication,
compared with less than a million in pigs as injectables
(data not shown). In pigs, usage of fluoroquinolones has
decreased since the withdrawal from the market in 1999
of a formulation for oral treatment. The apparent difference in levels of resistance and in trend among C. jejuni
from humans compared with broilers is interesting
(Figure 8). Epidemiological investigations have shown
that these animal species constitute important reservoirs
for human campylobacteriosis in Denmark. We have
found that the levels of resistance are higher in isolates
from incidents associated with travel abroad (Table 27),
and it is possible that the disparity may be explained by
some travel associated cases being misclassified as
domestically acquired, in addition to cases that are
acquired from imported foods.
Resistance in indicator bacteria
In DANMAP 2000 we reported how a particular
multiresistant clone of Enterococcus faecium had a
significant impact on the overall levels of resistance in
pigs and cattle. The clone was still present in 2001 but
with a decreased incidence. Overall, we have found a
rather good association between the phasing out of
antimicrobial growth promoters and resistance trends in
E. faecium from broilers and pigs as well as from broiler
meat and pork (Figures 10-15). The apparent poor
agreement seen for some resistance phenotypes
between isolates from domestic animals and from the
corresponding food product sampled in retail outlets
(Tables 32 and 33) is likely to result mainly from random
variation, considering the limited number of isolates in
some food categories. However, enterococci are able to
survive and perhaps proliferate in processing
environments, as seen from our finding in previous years
of enteroccocci in samples of fish. Enterococci in food
animal products may only partly reflect the populations in
the animals of origin.
In contrast, among Escherichia coli from animals at
slaughter there is good agreement with resistance levels
in the corresponding products. In general, resistance
levels are low, lower than in imported products. About
10% of isolates from broilers and broiler meat were
resistant to nalidixic acid and one E. coli isolate from
Danish broiler meat was resistant to ciprofloxacin. No
isolates were resistant to cephalosporins.
In 2002 the DANMAP group has initiated sampling of the
healthy human population to recover E. coli and
enterococci for susceptibility testing. The results will be
presented in future DANMAP reports.
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9
Resistance in bacteria from diagnostic
submission
Food animals. Comparison of results for E. coli from
diagnostic submissions (Table 37) with the results for
indicator E. coli show that resistance levels in the former
are the highest. While the trend in E. coli from broilers
generally is decreasing or the level is stable (Figure 17),
some of the trends in isolates from cattle and pigs are a
cause for concern. In cattle, quinolone resistance in E.
coli has – with one exception – been increasing since
1996.
In E. coli from pigs, tetracycline resistance is on the
increase, while quinolone resistance decreases. These
trends appear to be driven by usage trends. In a
previous report we have commented that the marketing
of apramycin in 1998 for use in pigs and calves might
lead to increase in resistance to gentamicin. This is the
possible cause of the increase in gentamicin resistance
observed in E. coli from cattle as well as in pigs from
2000 to 2001, however, the genetic basis for the
resistance has not yet been examined.
In staphylococci from cases of mastitis resistance levels
are relatively low, including resistance to penicillin. No
isolate was resistant to cephalosporins. In
Staphylococcus hyicus from pigs the resistance trends
appear somewhat variable (Figure 18). Part of this may
be explained by a relatively small number of isolates.
Other than that vi have no explanation for the variation.
Humans. DANMAP brings together resistance data for
some common human pathogens. Eleven of 16 Danish
counties now contribute their results. While it is apparent
that the overall trends are very similar in all parts of the
country, differences in surveillance methods still preclude
pooling of data and detailed analyses of trends relative
to antimicrobial consumption are not yet possible.
In 2000 we commented on an increase in occurrence of
methicillin resistant Staphylococcus aureus. This
increase continued in 2001 and while the incidence is
still low, it does represent a cause for concern.
10
__
___
DANMAP 2001
Demographic data
Table 1 shows the production of food animals, meat,
milk and fish. From 2000 to 2001, the number of cattle
slaughtered decreased by 5.5%, while the number of
poultry and pigs slaughtered increased by 2.2% and
2.6% respectively. The proportion of imported meat
consumed has been estimated at 36% for beef, 27% for
poultry and 10% for pork.
Table 2 provides information on the distribution of the
human population and on the health care system in
Denmark.
Table 1. Production of food animals and the production of meat, milk and fish,
Denmark, 1990-2001
Year
Poultry
Cattle
(slaughtered)
1,000 heads
mio. kg
789
219
1990
1,000 heads
98,686
1992
1994
111,536
120,349
150
167
862
813
1996
1998
111,495
129,334
165
185
2000
2001
136,934
140,015
197
a)
mio. kg
126
Dairy cows
DANMAP 2001
Pigs
Farmed fish
Fresh water Salt water
1,000 heads
753
mio. kg. milk
4,742
1,000 heads
16,427
mio. kg
1,260
mio. kg
mio. kg
236
210
714
700
4,605
4,642
18,559
20,760
1,442
1,604
35
35
7
7
789
733
198
179
701
669
4,695
4,668
20,530
22,873
1,592
1,770
32
32
8
7
691
653
171
a)
636
a)
4,720
a)
22,336
22,926
1,748
a)
33
31
7
a)
a) Data on the production of meat and fish, and no. of cows in 2001 was not yet available
Table 2. Distribution of the human population and health care structure by county,
Denmark
County no.
County name
DANMAP 2001
No. inhabitants
(1/1/2001)
499,148
91,076
615,115
No. inh./km2
(1/1/2001)
5,656
10,385
1,170
No. inh. /GP c)
(2001)
1,569
1,602
1,629
No. bed-days d)
(2000, provisional)
1,037,000 e)
597,000
No. hospitals
(2000)
4
1
3
1
Copenhagen Municipality a)
2
3
Frederiksberg Municipality a)
Copenhagen County b)
4
5
Frederiksborg
Roskilde
368,116
233,212
273
262
1,512
1,631
323,000
226,000
4
2
6
West Zealand
296,875
99
1,540
270,000
4
7
8
Storstroem
Bornholm
259,691
44,126
76
75
1,515
1,300
271,000
40,000
5
1
9
10
Funen
South Jutland
472,064
253,249
135
64
1,486
1,472
529,000
216,000
9
4
11
Ribe
224,446
72
1,537
206,000
4
12
13
Vejle
Ringkoebing
349,186
273,517
117
56
1,612
1,550
381,000
256,000
6
5
14
15
Aarhus
Viborg
640,637
233,921
140
57
1,561
1,562
701,000
254,000
9
3
16
All
North Jutland
Denmark
494,833
80
1,544
495,000
7
5,349,212
124
1,552
5,802,000
71
a) Inner Copenhagen.
b) Outer Copenhagen.
c) GP, general practitioner.
d) Excluding psychiatry, private hospitals and one rehabilitation center.
e) Public hospitals in Copenhagen and Frederiksberg municipalities (inner Copenhagen) represent one single administrative body.
DANMAP 2001
_
_______________
11
Antimicrobial use
In previous DANMAP reports we have shown trends in
antimicrobial usage based on sales figures reported by
the pharmaceutical industry. These data from the top of
the supply pyramid have – with some exceptions – not
included information on usage in individual target animal
species.
In 2000 we initiated a monitoring programme, VetStat,
where usage information is collected close to the point
of use. These data include information about – among
other things - target animal species and age group of the
animals. Please refer to Text box 1 for details about
VetStat data collection. In this DANMAP report we
compare usage data based on these two different types
of reporting. In the future, usage data collected by the
VetStat programme will replace the returns on annual
sales from the pharmaceutical industry.
Reports from pharmaceutical companies. These
data are comparable with data from previous years. In
our calculation of total quantity of active compound used,
we have - as in previous years – excluded antimicrobials
used only in companion animals, i.e. mainly
antimicrobials formulated as small tablets.
Table 3 compares usage in 2001 with results from 2000
and Figure 1 shows the trend from 1996 to 2001.
Overall, the quantity of antimicrobials used in production
animals (excluding aquaculture) amounted to 94,200 kg
active compound. This represents an increase of 17%,
which exceeds the increase in animal production. The
increase is mainly in antimicrobials for oral use, in
particular tetracyclines, macrolides/lincosamides and
extended spectrum penicillins. While we have no hard
data on usage in target animal species in these sales
returns from pharmaceutical companies, we know from
other sources that the major proportion of tetracyclines
and macrolides/lincosamides are used in pig
production.
In contrast to the increasing usage of oral formulations
and injectables, the quantities of antimicrobials for intramammary and intra-uterine use have remained rather
constant over the past five years (Figure 1). Intramammaries are used almost exclusively in dairy cattle,
where milk production has been quite stable at around
4,700 million kgs per year during the same period.
Point of use data (VetStat). VetStat usage data are
prescription-based and are collected from pharmacies,
veterinary practise and from feed mills. Antimicrobials
for therapeutic use can be legally obtained only through
pharmacies or – on the basis of a prescription from a
veterinarian – from a feed mill as medicated feed. Table
4 shows sales from pharmacies in kg active compound
by target animal species and age group. For some data
DANMAP 2001
100,000
Kg active compound
Usage of therapeutics in animals
80,000
60,000
40,000
20,000
0
1996
1997
Oral
1998
Injection
1999
Mammary
2000
Uterine
Figure 1.Trend in usage of antimicrobials for
treatment of food animals by route of administration
and usage of antimicrobial growth promoters
(AGPs)1996-2001, Denmark
Table 3. Usage of antimicrobials (kg active compound) for treatment of food animals by
route of administration, Denmark
DANMAP 2001
Antimicrobial group a)
Tetracyclines
Extended Spectrum Penicillins
Narrow Spectrum Penicillins
Oral
2000
2001
Injection
2000
2001
2001
AGP
Intramammary
2000
2001
Intrauterine
2000 2001
Total
2000
2001
21,200
4,500
0
24,800
5,600
0
2,800
3,000
14,700
3,200
3,500
17,000
<25
150
100
0
150
100
0
0
50
<25
0
50
24,000
7,600
14,800
27,900
9,300
17,100
Cephalosporins
Sulfonamides
Sulfonamides + trimethoprim
0
0
3,500
0
0
4,000
50
0
3,500
50
0
3,400
<25
0
50
50
0
<25
0
1,000
0
0
800
0
50
1,000
7,000 b)
100
800
7,400 b)
Macrolides + lincosamides
9,200
11,900
1,800
2,000
<25
0
0
0
11,100
14,300
Aminoglycosides
7,300
8,400
2,800
3,200
100
150
150
100
10,400
11,900
Fluoroquinolones
Others
Total
50
4,200
50,000
50
4,900
59,600
100
300
29,100
150
300
32,900
0
<25
400
0
<25
500
0
0
1,200
0
0
950
150
4,500
80,600
200
5,200
94,200
a) For a description of individual compounds included in each group, please refer to Text box 5
b) Does not include consumption in aquaculture
12
__
___
DANMAP 2001
Text box 1
Collection of data on antimicrobial usage at the point of use
The VetStat programme
Background
One of the key recommendations of the ‘Antimicrobial Threat’ invitational conference held in Copenhagen
in 1998 was that usage of antimicrobials in animal production should be monitored. While Denmark had
for some time monitored such usage on the basis of information provided from the top of the distribution
system (i.e. by the pharmaceutical industry), the Danish government decided to develop and implement
monitoring of usage of all prescription medicines closer to the point of use. The programme, VetStat,
started data collection in mid-2000. From 2001 the data were of sufficient quality to permit publication of
monthly usage statistics. These data are available at the Danish Zoonosis Centre homepage at
www.vetinst.dk.
VetStat collects data on usage of all prescription medicines prescribed or used by veterinarians, including
human medicines. VetStat also collects data on usage of antimicrobial growth promoters and
coccidiostats.
Description of data collection
All antimicrobials for treatment of disease are prescription-only medicines and available only through
pharmacies. Antimicrobials obtained by veterinarians for use in practise or for re-selling to clients must
also be purchased through pharmacies. The only exception to this is pre-mixes for use in medicated feed
produced at licensed feed mills. A farmer may obtain such feed on the basis of a veterinarian’s
prescription, however, the feed mill may obtain the pre-mix direct from a medical wholesaler or a
pharmaceutical company. Coccidiostats approved by the EU as feed additives are freely available.
Data in VetStat originates from three sources: pharmacies, large animal practices and feed mills.
Pharmacies. Information for use in VetStat is extracted automatically during electronic processing of
sales at the pharmacy, be it medicine ordered by a veterinarian for use in practice or a sale based on a
veterinary prescription redeemed by an animal owner. The data record describing each sale includes a
numerical code unequivocally identifying the type of medicine, including its formulation, strength and size
of pack; the quantity sold of each pack; codes for target animal species, age group and disease entity as
stated on the prescription (the two latter for production animals only); where applicable, a code identifying
the farm where the medicine will be used; codes identifying the prescribing veterinarian, the date of sale,
as well as other items of information. For medicines sold for use in practice, the type and quantity of
medicine as well as the receiving practice is identified.
The data are sent electronically on a monthly basis to the Danish Medicines Agency which forwards them
to the central VetStat database.
Veterinary practise. Veterinarians are required by law to report to VetStat the use of all prescription
medicines in production animals. The information to be reported includes the identity and quantity of
medicine, target animal species, age group and disease entity, farm ID, as well as information identifying
the veterinarian and the practice. Veterinarians are not presently required to report usage of medicines in
companion animals and horses.
For data collection, most practices use software that automatically extracts the information required by
VetStat during the billing procedure. In this case, there is no special data entry required.
Veterinarians also have the option of recording usage directly into the VetStat database, which can be
accessed via the internet.
Feed mills. Feed mills record sales of medicated feed directly into the database via the internet. The
information recorded includes a code identifying the active ingredient, its concentration, the quantity of
DANMAP 2001
_
_______________
13
Text box 1 continued ...
feed, as well as information identifying target animal species, age group, the farm, and the prescriber.
For coccidiostats, records identifying the type of coccidiostat, the concentration, the quantity of feed sold,
and the identity of the farm receiving it. The records are sent electronically to the VetStat database once a
month.
The database
The VetStat database is a relational database on an Oracle platform and is part of the so-called GLR/
CHR register, operated by LEC a/s on behalf of the Ministry of Food, Agriculture and Fisheries. The
Danish Zoonosis Centre is responsible for VetStat, however, its development and implementation has
taken place in close collaboration with the Danish Veterinary and Food Administration. VetStat is
integrated with a number of other databases, among them the central farm register which contains,
among other data, information about the number and species of animals at each holding.
Access to data
Veterinarians and farmers may access their data via a secure connection to the VetStat homepage on
the internet. Their access is restricted by password to registrations concerning their own clients or herds,
respectively. However, for comparative purposes they have access to standardised outputs showing
mean usage on other farms on a regional and national level. In order to make such comparisons
meaningful we have defined Animal Daily Dosages (ADD) for each combination of antimicrobial product
and animal species/age group. An ADD is, for any formulation, the daily dosage required to treat an
animal of a certain weight. We have used the manufacturers recommended dosages and when these
have been given as a range we have chosen the median value. We have also, for each species and age
group chosen a standard weight for each animal. So, for a given antimicrobial, we take the total quantity
active compound recorded as used for a species and age group and divide by the median dosage in mg
per kilogram and divide again with the standard weight chosen.
records with a valid code for animal species, information
about age group was not available and for some records
there was a valid farm code, but no information about
target animal species. These have separate entries in
the table. Furthermore, a substantial part of the total
quantity has been sold for use in veterinary practise.
Information about the animal species in which this has
been used is incomplete, however, the major proportion
is used in cattle, with most of the remainder in
companion animals. The VetStat data also include
human antibiotics prescribed for use in companion
animals, however this quantity is small and amounted to
275 kg active compound in 2001.
Table 5 shows sales of antimicrobials in medicated
feed. More than half of the total sales were for use in
aquaculture with the rest being used in pigs. The quantity
used in poultry amounted to less than 0.5 kg.
It is clear from these data that 74% of all antimicrobials
are used in pig production, while broilers, at the other
extreme, were responsible for less than 0.5% of the total
usage. Relative to production figures (2000 data), usage
of antimicrobials in pig production amounted to 41 mg/
kg and in broilers to 0.8 mg/kg of meat produced.
In Table 6 we present usage as Animal Defined
Dosages (ADD) based on prescription information. An
ADD is – for any formulation – the daily dosage required
to treat an animal of a certain weight. For calculation of
ADD’s, please refer to Text box 1. When evaluating the
data in Table 6, one must remember that it is based on
pharmacy data only. Usage in cattle to a large extent
consists on medicine purchased by the veterinarian for
use in practice. The data in Table 6 therefore
underestimates usage in cattle to a considerable degree
as information about usage by age group in this species
relies on information reported by veterinary practitioners.
This reporting was not complete in 2001. Furthermore,
as will be clear from an examination of Tables 4 and 5,
usage in aquaculture is largely by feed medication. For
this reason we have excluded usage in aquaculture from
the pharmacy-based information in Table 6 as the figure
would be quite misleading. For pigs and poultry,
however, the pharmacy records are fairly complete.
It is clear from Table 6 that in pig production by far the
most intensive usage is in weaner pigs. In 2001 152
million dosages were used in weaners, or 6.6 ADD per
pig produced, compared with 0.4 ADD per broiler.
14
__
Comparison of pharmaceutical industry data with
VetStat. In 2001 the total quantity of antimicrobials
reported by pharmaceutical companies amounted to
97,400 kgs, including use in aquaculture but excluding
preparations obviously intended for use in pets. In
contrast, sales from pharmacies and feed mills
amounted to only 96,200 kg, a difference of 1,200 kg.
We have been able to establish that the reason for some
of this discrepancy was that one pharmaceutical
company erroneously reporting some antimicrobials as
having been sold for domestic use, even though they
were in fact exported.
___
DANMAP 2001
information was provided by the Danish Plant
Directorate, for 2001 the data were obtained using
VetStat. Reporting of feed additive use in VetStat has
not been subject to final validation, however, the overall
usage information as presented in Table 7 is reasonably
correct. Nevertheless, the data should be interpreted
with some caution. It is clear from the table that almost all
coccidiostats used belong to the ionophore group of
compounds.
Antimicrobial growth promoters
Following the official ban on the growth promoter
virginiamycin in January 1998, the Danish food animal
industries decided to discontinue all further use of
growth promoting antimicrobials. This became effective
in broilers, slaughter pigs and cattle in February and
Coccidiostats
Table 7 shows usage of coccidiostats in poultry
production. In contrast to previous years where usage
Table 4. Antimicrobials sold from pharmacies in Denmark in 2001 (kg active compound) by animal species
and age group. Usage has been rounded to the nearest kg
DANMAP 2001
Animal species
Pigs
Cattle
Small ruminants
Poultry
Age group
Breeders and
suckling pigs
Amcol a)
Amglc
Ceph
FQ
Quinol
Linco
Macrol
Pen-sim
Pen-ext
Sulfa/TMP
Tet
Others
Total
1
2,431
20
52
0
516
1,574
5,852
2,343
2,922
2,904
1
18,617
Weaners
0
5,880
2
26
0
657
5,919
787
1,934
1,367
11,341
4
27,919
Slaughter pigs
0
636
2
14
0
1,002
5,815
3,202
1,362
201
9,794
0
22,028
Age not given
0
75
0
2
0
25
188
93
78
45
346
0
854
Cows, bulls
0
8
1
0
0
3
12
35
16
17
19
0
112
1,333
Calves < 12 months
31
270
1
8
0
8
29
480
100
157
249
0
Heifers, steers
1
2
0
0
0
0
2
9
5
1
10
0
29
Age not given
2
9
0
0
0
2
12
5
4
4
26
0
64
11
> 12 mdr.
0
2
0
0
0
1
1
2
1
4
1
0
< 12 mdr.
0
0
0
0
0
0
0
0
0
0
1
0
1
Age not given
0
0
0
0
0
0
2
2
0
0
2
0
6
160
Broilers
0
0
0
5
0
0
4
0
145
5
2
0
Layers
0
0
0
2
0
0
4
0
20
2
1
0
29
Rearing flocks
0
3
0
2
0
1
23
0
40
38
8
0
116
Age not given
0
0
0
3
0
0
2
0
10
7
1
0
23
Aquaculture
1
0
0
0
110
0
0
0
47
110
4
0
273
Horses
0
17
0
0
0
0
1
19
2
103
2
0
144
Other production
animals
1
34
5
1
0
3
13
38
38
31
10
1
176
Mink
0
166
0
1
0
34
65
0
341
33
19
0
659
Use in practise or
species not given
56
1,807
206
51
156
162
966
5,385
1,991
2,939
1,494
35
15,246
Farm identified
3
429
2
12
7
106
668
478
455
311
875
0
3,346
Pets
1
110
62
4
0
9
21
32
81
90
29
13
453
98
11,880
302
183
273
2,530
15,324
16,420
9,010
8,391
27,135
54
91,602
a) Amcol: amphenicols; Amglc: aminoglycosides; Ceph: cephalosporins; FQ: fluoroquinolones; Quinol: quinolones; Linco: lincosamides; Macrol:
macrolides; Pen-sim: simple penicillins; Pen-ext: penicillins with extended spectrum; Sulfa/TMP: sulfonamide and sulfonamide-trimethoprim
combinatin; Tet: tetracycline. For a description of individual compounds included in each group, please refer to Text box 6
Table 5. Sales of antimicrobials as medicated feed in kg active compound by animal species and age group, Denmark
DANMAP 2001
Animal species
Age group
Amcol a)
Amglc
Quinol
Linco
Macrol
Sul/TMP
Tet
Pigs
Breeders, sucklers
0
1
0
3
56
25
61
Total
145
Pigs
Weaners
0
3
0
3
306
32
1,133
1,476
Pigs
Slaughter pigs
141
0
1
0
6
56
0
77
Poultry
0
0
0
0
0
0
0
0
Aquaculture
96
0
266
0
0
2,521
0
2,883
Total
96
4
266
12
419
2,577
1,271
4,646
a) For abbreviation, please refer to Table 4
DANMAP 2001
_
_______________
March of that year and in weaner pigs during 1999. In
2000 antimicrobial growth promoters were not used.
However, in 2001 reporting through the VetStat pro-
gramme showed the use of very small quantities of
flavomycin (11 kg) and avilamycin (3 kg), both among the
four growth promoters still approved by the EU (Table 8).
Table 6. Usage of antimicrobials given as Animal Defined Dosages (ADD's), based on
sales from pharmacies to animal owners, Denmark
DANMAP 2001
Animal species
Age group
Pigs
Cattle
Small ruminants
Standard weight (kg)
Kg antimicrobial
Breeders and suckling pigs
200
Weaners
15
Slaughter pigs
Age not given
50
-
Cows, bulls
600
Calves < 12 months
100
Heifers, steers
300
29
9
-
Age not given
-
64
-
4,219
> 12 mdr.
50
11
12
-
< 12 mdr.
20
1
2
-
-
6
-
185
Age not given
Poultry
ADD
(1000's)
Kg animal treated
(1000's)
18,617
6,787
-
27,918
151,740
-
22,028
37,371
-
854
-
71,230
112
30
-
1,333
946
-
Broilers
0.2
161
56,764
-
Layers
1
29
1,698
-
Rearing flocks
1
116
3,640
-
Age not given
-
23
-
1,132
Horses
-
144
9
-
Mink
1
659
36,604
-
Total kg antimicrobial
-
72,380
-
-
Table 7. Usage of coccidiostats in poultry (kg active compound),
Denmark
DANMAP 2001
Coccidiostats
Amprolium/Ethopabat
1990
3,562
1992
2,716
1994
2,342
1996
1,339
1998
275
1999
839
2000
-
2001
13
Dimetridazol
-
-
-
38
-
106
-
-
DOT
-
-
300
-
-
13
-
-
Monensin
Robenidin
Metichlorpindol/
Methylbenzoat
33
108
295
1,016
858
3,405
293
3,709
367
8,664
85
3,962
-
1,361
2
89
1,503
3,360
4,857
930
155
-
-
Lasalocid
75
-
5
773
1,677
895
606
872
Halofuginon
Narasin
1,588
5,157
19
6,370
8
3,905
3,177
2
5,806
5,073
2,687
Salinomycin
12,801
7,783
10,298
6,018
4,531
7,884
8,812
6,338
Nicarbazin
-
-
-
115
36
4
-
-
Narasin/Nicarbazin
Nifursol
-
395
-
146
234
32
79
20
-
1
-
13,569
20,472
18
20,306
34
19,444
3
18,292
1
25,493
15,999
2
17,739
Diclazuril
Total
Table 8. Usage of antimicrobial growth promoters (kg active compound),
Denmark
Antibiotic group
Bacitracin
Growth promoter
Bacitracin
Flavofosfolipol
Flavomycin
Glycopeptide
Ionophore
Avoparcin
Monensin
Macrolides
Spiramycin
Tylosin
1990
3,983
1992
5,657
DANMAP 2001
1994
13,689
1996
8,399
1998
3,945
1999
63
2000
-
2001
-
494
1,299
77
18
6
665
-
11
13,718
2,381
17,210
3,700
24,117
4,755
4,741
935
-
-
-
12
a)
-
-
213
759
113
-
-
-
26,980
95
37,111
15
68,350
0.3
13,148
1,827
-
3
Salinomycin
42,632
Oligosaccharides
Avilamycin
10
853
433
2,740
7
91
-
Quinoxalines
Carbadox
850
7,221
10,012
1,985
1,803
293
-
-
11,391
3,837
79,308
21,193
15,537
99,650
22,483
2,801
115,786
13,486
5,055
105,548
28,445
892
49,294
9,344
12,283
-
14
Streptogramins
Total
Olaquindox
Virginiamycin
a) - indicates that the compound was not used
15
16
__
___
DANMAP 2001
Text box 2
Few antimicrobial residues in slaughtered
animals, eggs and milk
For almost 15 years between January 1987 and April 2001 the Danish Veterinary and Food Administration has carried out intensive surveillance of the antimicrobial residues in slaughter animals, eggs and
milk. The sampling scheme was stratified random and included samples from 0.1% of the annual
production of fattening pigs, 1.0% of the sows slaughtered, 0.5% of the adult cattle and 0.2% of the
fattening calves. The analytical method used was the official EU reference microbiological test, which was
sufficiently sensitive for most but not all of the relevant substances. The risk of false negative results was
estimated by aid of specific chemical methods of analysis (see below).
On the basis of examination of approximately 200,000 slaughter pigs over the 15-year period, it was
concluded that the frequency of violations of residue limits was 0.02% which is extremely low by international standards. For this reason, the frequency of sampling was drastically reduced in May 2001.
In recent years positive screening results were verified by quantitative chemical methods. In cases where
the latter showed that the residue was less than the EU defined Maximum Residue Level (MRL), the
screening result was declared false positive and the final result as negative.
In 2001, a total of 9,339 randomly selected slaughter pigs were analysed with no positives. Likewise,
1,064 cattle, 12 sheep and 3 horses were analysed with no positives. We also found no violations in 334
samples of poultry, 98 samples of fish from aquaculture, 256 samples of milk taken by the official
inspectors, 140 samples of eggs, 10 samples of farmed game and 34 samples of honey. However, we
found 2 violations in samples from 1,424 sows, corresponding to 0.14%, a level similar to that found in
sows in recent years.
Milk samples are also collected by non-official staff on all dairy farms 13 times a year. During the period
1993 - 1999, we found violations of MRLs in 0.04% of the samples. In 2000 and 2001, the total number of
samples was 242,173. Seventy-one of the samples corresponding to 0.03% had higher residues than
permitted. The most frequently detected antimicrobial residues were simple penicillins, including
benzylpenicillin, with less frequent findings of sulfamethazine, cloxacillin and ampicillin residues. Residues
of sulfadiazin, amoxicillin and oxytetracycline were very rarely found.
The application of the official EU reference microbiological test was chosen on the basis of a cost-benefit
analysis since the analysis of huge numbers of samples was economically affordable only in this case. In
order to evaluate the performance of the test with respect to the frequency of false negative results we
have recently implemented the use of specific methods of analysis for those substances which are not
sufficiently detected by the microbiological method. In 2001, these tests found no violations in 779 porcine
and 99 bovine samples that comprise the vast majority of slaughter animals.
Comparison with other European Member States should be done with great caution since information on
risk groups (for instance the proportion of sows and boars versus fattening pigs) and the applied analytical
methods is often lacking. For example, in Denmark kidney tissue is analysed, because most of the
antibiotics are concentrated there, whereas other countries analyse muscle tissue.
Annual reports in Danish on monitoring residues in food are made available on the Internet under ’Publikationer’ at the homepage of the Danish Veterinary and Food Administration.
Further information on the monitoring of residues in Denmark and Europe can be obtained from Senior
Scientific Adviser Flemming Kæreby ([email protected]).
DANMAP 2001
_
_______________
Text box 3
Veterinary antimicrobial treatment guidelines
The use of antimicrobial agents for treatment of food animals implies a risk of selection for antimicrobial
resistant bacteria. The Danish Veterinary Institute introduced a veterinary antibiotic policy for prudent use of
antimicrobial agents in 1997. This policy takes into account the need to treat animals efficiently and at the
same time to minimize possible negative impact on human health by the emergence of resistance. General
guidelines for veterinary use of antimicrobials may be valuable as part of an overall strategy for limiting the
emergence and spread of antimicrobial resistance. However, to be useful on a daily basis the policy has to
include guidelines for choice of antimicrobial agents for specific infections. The Danish veterinary antibiotic
policy is based on knowledge of the resistance patterns in Denmark. Such knowledge is a prerequisite for
the development of an operational policy.
Main principles for prudent use of antimicrobial agents for treatment of food animals
Prudent use of antimicrobial agents in veterinary medicine is important to ensure efficacious treatment of
diseased animals, but also to limit the negative consequences as much as possible. The implementation of
antimicrobial treatment must be based on an aetiological diagnosis. This may be based on clinical signs.
However, in many cases a laboratory diagnosis is necessary. For some bacterial species the susceptibility
can be predicted with great certainty. This includes e.g. Erysipelotrix rhusiopathiae and beta-haemolytic
streptococci. For other species, such as E. coli, Salmonella and staphylococci, the susceptibility patterns
vary. It is the veterinarians’ responsibility to have thorough knowledge of the susceptibility patterns in the
different herds under his/her care. The effect of empirically initiated treatment should be monitored and
evaluated. The choice of antimicrobial treatment should be adjusted if indicated by the susceptibility test or
lack of effect. In Denmark, all antimicrobial agents used for treatment of animals are prescription-only
medicine.
Choice of antimicrobial agent
For the most common bacterial infectious diseases among food animals in Denmark, suggestions for
choice of antimicrobial treatment are given as 1 st , 2nd and 3 rd priority. If prophylaxis using vaccination is most
appropriate, no antimicrobial agent is recommended. These recommendations are revised once annually
and published in the “Users manual” of The Danish Veterinary Institute.
Concerning the choice of antimicrobial agents for individual infections the following points have been taken
into consideration:
o
o
o
o
Narrow spectrum antimicrobials (penicillin) are given first priority
General occurrence of resistance to the given bacterial species
Expected clinical effect
Mode of administration
Only antimicrobial agents that are approved for treatment of the given food animal species, are included.
First priority antimicrobials are suggested as the drug of choice for a specific infection. Second priority
antimicrobials can be used when occurrence of resistance or mode of administration exclude the 1 st priority
antimicrobials. Third priority antimicrobials should only be used after susceptibility testing, and when specific
circumstances exclude 1 st and 2 nd priority antimicrobials. All antimicrobial agents where more than 70% of
the bacteria are resistant are excluded from the recommendations, and antimicrobials where more than 40%
are resistant are not given higher than 3 rd priority.
17
18
__
___
DANMAP 2001
Text box 3 continued ...
Exclusion or downgrading of certain antimicrobial agents
For precautionary reasons and to protect human health, certain antimicrobial agents are given low priority.
In Denmark, the occurrence of antimicrobial resistance is generally low, and it is often possible to exclude
certain antimicrobial agents from the list without limiting the possibilities to treat animals.
Fluoroquinolones and gentamicin are important antimicrobials in the treatment of gastrointestinal
infections, septicaemia and meningitis in humans. Methicillin is important in the treatment of infections
caused by staphylococci in humans. Thus, quinolones, gentamicin, cloxacillin and nafcillin are totally
excluded from the list of suggested antimicrobial agents.
A number of other antimicrobial agents have been downgraded. These are ceftiofur, cefoperazone,
tetracycline and lincospectin. Ceftiofur and cefoperazone are downgraded because, as third generation
cephalosporins, they may select for broadspectrum penicillin resistance. Tetracyclines are downgraded
because this group of antimicrobials can select for multiple resistance. Lincospectin is downgraded
because it is not suitable to use combination treatment when a single drug can be used.
Further information on the veterinary antimicrobial treatment guidelines can be obtained from Veterinary
Consultant Sven Erik Lind Jorsal ([email protected]).
DANMAP 2001
_
Human consumption
Overall
In 2001, overall consumption of antibacterials for
systemic use (ATC Group J01, 2001 definition) in
humans in Denmark amounted to 27.9 million DDDs or
14.3 DDD/1,000 inhabitant-days. To allow comparison
with consumption in food animals, we also present data
as kilograms of active compounds (Table 9). In 2001,
approximately 42 tonnes of antibacterials were used in
humans in Denmark, which represents an increase as
compared to 2000.
Primary health care sector
Table 10 presents the consumption of antibacterials for
systemic use in primary health care from 1997 to 2001
calculated using the 2001 update of the ATC
classification (includes nitrofurantoin and methenamine).
As for previous years, beta-lactamase sensitive
penicillins (mostly phenoxy-methylpenicillin) represented
38% of total antimicrobial use in 2001. Other frequently
used antimicrobials were penicillins with extended
spectrum (mostly amoxicillin, pivampicillin and
pivmecillinam) and macrolides, each representing
_______________
19
approximately 19% and 16%, respectively. Detailed
data on the consumption of the various macrolides is
presented in Figure 2. Finally, in 2001, fluoroquinolones,
combinations of penicillins including beta-lactamase
inhibitors (essentially amoxicillin + clavulanate) and
cephalosporins only represented 1.3%, 0.2% and 0.2%
of the total consumption in primary health care,
respectively.
Total consumption in primary health care showed a 5%
increase between 2000 and 2001. Beta-lactamase
sensitive penicillins, penicillins with extended spectrum
and macrolides were responsible for more than 75% of
this increase. Further analyses revealed that excessive
use was mainly observed in March and April and to a
lesser extent in October 2001 (Figure 3). This excess
occurred at the same time in all Danish counties (Figure
4), there were differences in the overall level of
consumption consistent with what has been observed in
past years. Among penicillins with extended spectrum,
the pattern of peaks in March and October was not seen
for pivmecillinam, which is only used to treat urinary tract
infections. Additionally, the pattern was not seen for other
classes of antibacterials that are not used to treat
Table 9. Consumption of antibacterials for systemic use in humans (kg active compound), Denmark.
These data must only be used for comparison with consumption in food animals. For monitoring in human
primary health care and hospitals, the correct way of expressing consumption is to use DDDs per population-days (see Tables 10 and 11). Consumption in kg active compound has been recalculated from original
data expressed as a number of DDDs and includes both primary health care and hospitals. These data
therefore represent an estimate of consumption expressed as a number of kg active compound
DANMAP 2001
ATC group a) Therapeutic group
Year
1997
1998
1999
2000
2001 (low est.-high est.) b)
1,692
1
1,692
1
1,590
0
1,701
1
1,705
0
5,513
18,813
5,467
19,947
5,181
18,790
5,135
19,782
5,371
20,715
1,913
48
2,115
55
2,416
51
2,654
51
3,225
144
660
245
657
256
685
258
727
263
785
280
Short-acting sulfonamides
Combinations of sulfonamides and trimethoprim, incl. derivatives
3,498
337
3,493
322
3,289
279
3,148
285
3,111
283
J01FA
J01FF
Macrolides
Lincosamides
4,227
28
4,536
38
4,147
33
4,040
33
4,089
42
J01G
J01MA
Aminoglycosides
Fluoroquinolones
32
320
31
343
32
321
32
290
28
335
J01MB
J01XA
Other quinolones
Glycopeptides
15
25
17
27
16
32
0
37
0
36
J01XC
J01XD
Steroid antibacterials (fusidic acid)
Imidazoles
74
128
73
127
78
140
70
154
59
168
J01XE
J01XX
Nitrofuran derivatives
Other antibacterials (methenamine)
137
2,233
141
2,132
141
1,956
149
1,792
152
1,637
(1,309-1964)
J01
Antibacterials for systemic use (Total) c)
39,938
41,469
39,436
40,344
42,163
(40,185-44,142)
J01AA
J01B
Tetracyclines
Amphenicols
J01CA
J01CE
Penicillins with extended spectrum
Beta-lactamase sensitive penicillins
J01CF
J01CR
Beta-lactamase resistant penicillins
Combinations of penicillins, incl. beta-lactamase inhibitors
J01D
J01EA
Cephalosporins and related substances
Trimethoprim and derivatives
J01EB
J01EE
(364-1,205)
(2,966-5,212)
(34-51)
(236-434)
a) From the 2001 edition of the Anatomical Therapeutic Chemical (ATC) classification system
b) When 2 different DDDs existed for different presentations, e.g. oral and parenteral, of an antimicrobial, i.e. for cefuroxime, erythromycin, clindamycin,
ciprofloxacin and methenamine, an average DDD was used. For 2001, extremes values, i.e. estimates using the lowest and the highest DDD, are given
in parentheses
c) Does not include polymyxins
20
__
___
DANMAP 2001
Table 10. Consumption of antibacterials for systemic use in primary health care (DDD/1,000 inhabitantdays), Denmark
DANMAP 2001
ATC group a)
Therapeutic group
Year
J01AA
Tetracyclines
1997
0.98
1998
0.98
1999
0.93
2000
0.98
2001
0.99
J01CA
J01CE
Penicillins with extended spectrum
Beta-lactamase sensitive penicillins
2.39
4.57
2.39
4.81
2.29
4.48
2.30
4.70
2.47
4.91
J01CF
J01CR
Beta-lactamase resistant penicillins
Combinations of penicillins, incl. beta-lactamase inhibitors
0.34
0.02
0.40
0.03
0.48
0.02
0.52
0.02
0.65
0.03
J01DA
J01EA
Cephalosporins and related substances
Trimethoprim and derivatives
0.02
0.30
0.03
0.32
0.02
0.32
0.02
0.33
0.03
0.35
J01EB
J01EE
Short-acting sulfonamides
Combinations of sulfonamides and trimethoprim, incl. derivatives
0.41
0.08
0.41
0.04
0.38
0.03
0.37
0.03
0.36
0.04
J01FA
J01FF
Macrolides
Lincosamides
2.03
0.01
2.28
0.01
2.17
0.01
2.02
0.01
2.10
0.01
J01MA
J01XB
J01XC
Fluoroquinolones
Polymyxins
Steroid antibacterials (fusidic acid)
0.22
0.03
0.02
0.23
0.02
0.02
0.20
0.03
0.02
0.15
0.03
0.02
0.17
0.02
0.01
J01XE
J01XX
Nitrofuran derivatives (nitrofurantoin)
Other antibacterials (methenamine)
0.35
0.46
0.36
0.43
0.36
0.40
0.38
0.36
0.39
0.33
J01
Antibacterials for systemic use (Total)
12.24
12.76
12.14
12.25
12.85
a) From the 2001 edition of the Anatomical Therapeutic Chemical (ATC) classification system
In the DANMAP 2000 report, we presented the decrease
in consumption of fluoroquinolones following removal of
their subsidisation in May 1999. Despite a slowly
increasing trend somewhat parallel to the one that was
observed before the change in reimbursement, the
reduction in fluoroquinolone consumption achieved by the
change in subsidisation has been maintained in 2001
(Figure 5). The latest change in subsidisation of
antimicrobials took place on 1 st March 2000 when a new
policy started to be applied to all subsidised medicines
including those antimicrobials that were still subsidised,
i.e. penicillins, sulfonamides, trimethoprim, macrolides,
fusidic acid and nitrofurantoin. In short, adults must have
purchased 500 DKK worth of prescription medicines
during the past year before the insurance system started
subsidising 50% of the price. This rule does not apply to
children below 18 years of age that receive 50%
subsidisation. Additionally, higher percentages of
subsidisation are applied to annual purchases over
1,200 DKK and again over 2,800 DKK for both adults
and children. As of now, this change does not seem to
have had an impact on total consumption of
antibacterials in primary health care (Figure 6).
Hospitals
Table 11 presents the consumption of antibacterials for
systemic use in hospitals from 1997 to 2001. Total
consumption in hospitals was 457 DDD/1,000 bed-days
in 2000 and estimated to be approximately 484 DDD/
1,000 bed-days in 2001. Use in hospitals may comprise
small amounts of antibacterials given to outpatients,
whereas the number of bed-days does not include
outpatient care. Therefore, hospital consumption data in
this report are likely to be slightly overestimated.
DANMAP 2001
DDD/1,000 inhab.-days
respiratory tract infections, such as sulfonamides,
trimethoprim or fluoroquinolones. These findings suggest
a link with outbreaks of respiratory tract infections. In
2001, there was marked peak of influenza activity in
February, i.e. a few weeks before the increase in
antimicrobial use. Additionally, we identified, in February
and March 2001, a clearly increased frequency of articles
on bacterial meningitis published in the major Danish
newspapers. These articles were commenting on an
outbreak of meningococcal meningitis in Denmark,
including reports on the death of a patient following
misidentification of disease, and could well have resulted
in more concern about meningitis among parents and
general practioners, and thus in more prescriptions of
antimicrobials. Nevertheless, the reason for the overall
increase in antimicrobial use in primary health care in
2001 remains unexplained.
1.5
1
0.5
0
1994
1995
1996
1997
Erythromycin (J01FA01)
Clarithromycin (J01FA09)
1998
1999
2000
2001
Roxithromycin (J01FA06)
Azithromycin (J01FA10)
Figure 2. Consumption of macrolides (J01FA) for
systemic use in primary health care, Denmark,
1994-2001
DANMAP 2001
_
_______________
DANMAP 2001
DDD/1,000 inh.-days
8
6
J01CE - 2001
J01CE - 2000
4
2
DDD/1,000 inh.-days
4
Ju
ly
Au
g
Se us
pte t
m
be
r
Oc
tob
No er
ve
m
b
De er
ce
m
be
r
Ap
ril
M
ay
Ju
ne
M
arc
h
Ja
nu
ar
Fe y
bru
ary
0
DANMAP 2001
3
J01CA - 2001
J01CA - 2000
2
1
DANMAP 2001
4
DDD/1,000 inh.-days
Ju
ly
Au
g
Se us
pte t
m
be
r
Oc
tob
No er
ve
m
b
De er
ce
m
be
r
Ap
ril
M
ay
Ju
ne
M
ar
ch
Ja
nu
ar
Fe y
bru
ary
0
3
J01FA - 2001
J01FA - 2000
2
1
Ju
ly
Au
Se gus
pte t
m
be
r
Oc
tob
No er
ve
m
b
De er
ce
m
be
r
Ap
ril
M
ay
Ju
ne
Ja
nu
ar
Fe y
br
ua
ry
M
ar
ch
0
Figure 3. Monthly consumption of beta-lactamase sensitive penicillins (J01CE), penicillins with extended
spectrum (J01CA) and macrolides (J01FA) in primary health care, Denmark, 2000-2001
21
DDD/1,000 inh.-days
DDD/1,000 inh.-days
6
4
Ju
ly
Au
Se gus
pte t
m
be
r
Oc
to
No ber
ve
m
be
De
r
ce
m
be
r
Ap
ril
M
ay
Ju
ne
M
arc
h
Ja
nu
ar
Fe y
bru
ary
Ju
ly
Au
g
Se us
pte t
m
be
r
Oc
tob
No er
ve
m
b
De er
ce
m
be
r
Ap
ril
M
ay
Ju
ne
Ja
nu
ar
Fe y
br
ua
ry
Ma
rch
DDD/1,000 inh.-days
8
Ju
ly
Au
Se gu
pte st
m
be
r
Oc
tob
No er
ve
m
b
De er
ce
m
be
r
Ju
ne
Ap
ril
M
ay
Ja
nu
ar
Fe y
br
ua
ry
Ma
rch
22
__
___
4
2
DANMAP 2001
DANMAP 2001
6
J01CE
2
0
DANMAP 2001
4
J01CA
2
0
DANMAP 2001
3
J01FA
1
0
Figure 4. Monthly consumption of beta-lactamase sensitive penicillins (J01CE), penicillins with extended
spectrum (J01CA) and macrolides (J01FA) in primary health care, by county, Denmark, 2001
DANMAP 2001
_
_______________
Nevertheless, comparison with those few data available
from other countries show that antimicrobial
consumption in Danish hospitals is among the lowest. In
2001, all penicillins combined represented almost 60%
of hospital antimicrobial use in Denmark.
Cephalosporins (mainly cefuroxime) and
fluoroquinolones (mainly ciprofloxacin) only represented
12.1% and 6% of total hospital use, respectively.
Tetracyclines, combinations of penicillins incl. betalactamase inhibitors, carbapenems and glycopeptides
each represented less than 1% of total hospital use.
Although the prescription of antimicrobials in Danish
hospitals can be described as conservative, there has
been a steady increase in hospital antimicrobial
consumption overall and for specific classes including
cephalosporins, fluoroquinolones and combinations of
penicillins incl. beta-lactamase inhibitors (Table 11). This
increase was mainly due to a 13% increase in the
number of DDDs of antimicrobials registered by hospital
pharmacies (numerator) from approximately 2.3 million
DDDs in 1997 to 2.7 million DDDs in 2000, while there
was only a 3% decrease in the total number of hospital
DDD/1,000 inh.-days
Change in subsidisation
from 50% to 0%
0.3
DANMAP 2001
0.2
jan
-0
1
jan
-0
0
jan
-9
9
jan
-9
8
jan
-9
7
0.1
Figure 5. Monthly consumption of fluoroquinolones (J01MA) in primary health care, Denmark, January
1997 - December 2001
Removal of specific
rule for subsidised antibacterials New policy applicable to
all subsidised medicines
DDD/1,000 inh.-days
22
20
18
16
DANMAP 2001
14
12
10
jan
-0
1
jan
-00
jan
-99
jan
-9
8
8
jan
-9
7
23
Figure 6. Monthly consumption of antibacterials for systemic use (J01, 2001 definition) in primary health
care, Denmark, January 1997 - December 2001
24
__
bed-days registered in Denmark (denominator) between
1997 and 2000. However, the average length of stay in
Danish hospitals decreased from 5.7 days in 1997 to
5.2 days in 2000. An explanation for the increase in
hospital antimicrobial consumption could therefore be
that, as a result of earlier discharge, bed-days
___
DANMAP 2001
registered by hospitals may now originate from sicker
patients. It could also be that to expedite discharges
patients now receive more intensive treatment.
Nevertheless, and because it concerns so-called “broadspectrum” antimicrobials, this increase is of concern and
deserves close surveillance.
Table 11. Consumption of antibacterials for systemic use in hospitals (DDD/1,000 bed-days). This
represented more than 98% of the total DDDs used in hospitals in Denmark in 2001. Psychiatric
hospitals, private hospitals and one rehabilitation center were excluded.
DANMAP 2001
ATC group a)
Therapeutic group
Year
1997
1998
1999
2000
2001 b)
3.3
108.6
3.2
109.6
2.7
108.1
2.8
112.5
2.8
114.4
105.4
59.6
J01AA
J01CA
Tetracyclines
Penicillins with extended spectrum
J01CE
Beta-lactamase sensitive penicillins
77.2
85.9
91.7
98.4
J01CF
J01CR
Beta-lactamase resistant penicillins
Combinations of penicillins, incl. beta-lactamase inhibitors
43.2
0.3
44.4
0.4
46.8
0.4
52.4
0.9
J01DA
J01DF
Cephalosporins
Monobactams
44.7
0.6
46.5
0.1
49.9
0.1
53.7
0.2
3.6
2.4
3.2
3.9
4.2
4.0
12.4
4.2
12.7
3.6
12.3
3.6
12.0
4.3
12.3
13.4
32.4
1.7
58.8
0.1
J01DH
Carbapenems
J01EA
J01EB
Trimethoprim and derivatives
Short-acting sulfonamides
J01EE
Combinations of sulfonamides and trimethoprim, incl. derivatives
4.4
12.9
13.6
13.9
J01FA
J01FF
Macrolides
Lincosamides
33.7
1.3
34.0
1.8
32.1
1.4
32.0
1.6
J01GB
J01MA
Aminoglycosides
Fluoroquinolones
19.5
14.3
19.5
15.1
20.2
18.4
21.0
22.7
18.4
27.9
J01XA
Glycopeptides
2.1
2.3
2.8
3.2
J01XB
J01XC
Polymyxins
Steroid antibacterials (fusidic acid)
0.4
2.5
0.2
2.4
0.3
2.6
0.4
2.3
3.2
0.3
J01XD
J01XE
Imidazoles
Nitrofuran derivatives
13.9
0.6
14.0
0.5
15.8
0.3
17.6
0.4
J01XX
Other antibacterials (methenamine)
J01
Antibacterials for systemic use (Total)
1.7
2.0
19.6
0.3
1.7
1.8
1.5
1.4
1.3
392.4
413.9
428.0
457.1
484.0
a) From the 2001 edition of the Anatomical Therapeutic Chemical (ATC) classification system.
b) Estimated consumption using the exact number of DDDs and an estimate of the number of bed-days in 2001 based on past trends.
DANMAP 2001
_
_______________
25
Resistance in zoonotic bacteria
Salmonella
Table 12 shows the Salmonella serotype distribution of
isolates from food animals, food and humans. The
phage type distributions of Salmonella Typhimurium and
Salmonella Enteritidis are presented in Tables 13 and
14.
Salmonella from food animals
Salmonella isolates from pigs and poultry (broilers and
layers) were mainly from subclinical infections, while the
majority of isolates from cattle were from clinical cases
of salmonellosis. Only one isolate of each serotype per
farm was included in this report.
Table 12. Distribution (%) of Salmonella
serotypes isolated from animals, foods and
humans among the isolates selected for
susceptibility testing, Denmark
DANMAP 2001
Serotypes
Poultry Broiler meat
Agona
3
Derby
1
34
11
Hadar
3
7
Infantis
9
5
Senftenberg
1
<1
Typhimurium
20
2
Newport
Virchow
Others incl.
not typable
Number of
isolates
Beef
Pigs
Pork
Humans
<1
Dublin
Enteritidis
Cattle
1
5
1
2
11
18
1
51
67
<1
4
<1
1
<1
7
49
1
2
8
<1
9
1
<1
35
7
65
<1
14
20
6
1
28
59
11
24
16
54
17
74
161
88
42
338
76
2,918
Table 13. Distribution (%) of Salmonella
Typhimurium phages types from animals, food
and humans among the isolates selected for
susceptibility testing, Denmark
DANMAP 2001
Phage type
1
3
12
17
66
104/104a/104b
Poultry
Cattle
Pigs
<1
<1
Pork
Humans
3
4
40
23
10
38
9
9
20
4
3
10
6
6
18
1
15
16
2
7
120
135
170
193
Others incl.
not typable
Number of
isolates
3
26
53
15
10
31
<1
10
9
When comparing the results from Table 15 with the
corresponding results from 2000 the resistance levels
among S. Enteritidis have remained almost unchanged.
In contrast to previous years none of the S. Enteritidis
isolates from poultry were resistant to nalidixic acid.
Among S. Typhimurium isolates from cattle, resistance
to tetracycline, sulfamethoxazole and streptomycin
remained unchanged in 2001 despite a reduction in the
percentage of pentaresistant DT104 isolates, from 35%
in 2000 to 10% in 2001. Among non-DT104 phage types
from cattle, resistance to tetracycline, sulfonamide and
streptomycin increased from 17% [6.6; 33.7], 20% [8.4;
36.9] and 17% [6.6; 33.7] to 36% [18.6; 55.9], 36%
[18.6; 55.9] and 39% [21.5; 59,4], respectively from
2000 to 2001. With a sample size of 35 isolates in 2000
and 28 isolates in 2001, these differences were
statistically non-significant.
From 1996 to 1999, the level of tetracycline resistance in
S. Typhimurium isolates from pigs was almost
unchanged. We have seen a significant increase in
Table 14. Distribution (%) of Salmonella Enteritidis
phages types from animals, food and humans
among the isolates selected for susceptibility
testing, Denmark
DANMAP 2001
Phage type
1b
1
Poultry
Broiler meat
12
Humans
18
<1
5
4
8
59
24
2
3
6
12
6
4
8
21/21b
18
5
31
36
37
11
Tables 15 and 16 show the MIC distribution and the
occurrence of resistance in S. Enteritidis from poultry
and in S. Typhimurium from poultry, cattle and pigs in
2001.
7
5
218
Due to the high number of Salmonella isolates from
pigs a representative subsample was randomly selected
among all Salmonella pig isolates that were serotyped
at the Danish Veterinary Institute in 2001. In contrast, the
Salmonella samples from cattle and poultry consisted of
one isolate from all farms where Salmonella was
detected.
569
6a
34
Others incl. not typable
Number of isolates
18
32
8
2
30
4
4
12
24
19
25
17
637
26
__
___
DANMAP 2001
Table 15. Distribution of MICs and occurrence of resistance among Salmonella
Enteritidis from poultry (n=25), Denmark
DANMAP 2001
Compound
% Resistant
[95% Confidence interval]
Tetracycline
4
[0.1-20.4]
Chloramphenicol
0
[0.0-13.7]
Florfenicol
0
[0.0-13.7]
Ampicillin
4
[0.1-20.4]
Ceftiofur
0
[0.0-13.7]
Sulfonamide
0
[0.0-13.7]
Trimethoprim
0
[0.0-13.7]
Apramycin
0
[0.0-13.7]
Gentamicin
0
[0.0-13.7]
Neomycin
0
[0.0-13.7]
Spectinomycin
0
[0.0-13.7]
Streptomycin
0
[0.0-13.7]
Distribution (%) of MICs
<=0.03 0.06 0.12 0.25 0.5
1
2
4
8
16
32
96.0
64
128 256
512
4.0 a)
52.0 48.0
96.0
4.0
76.0 20.0
4.0
44.0 56.0
52.0 44.0
4.0
100
96.0
4.0
92.0
8.0
100
100
36.0 64.0
Ciprofloxacin
0
[0.0-13.7]
Nalidixic acid
0
[0.0-13.7]
88.0
12.0
88.0 12.0
Colistin
0
[0.0-13.7]
96.0
4.0
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater
than the highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the
lowest concentration
resistance to tetracycline from 14% in 1999 to 25% in
2000 and 30% in 2001 (Figure 7). This is not explained
by increased occurrence of S. Typhimurium DT104
among the isolates. The increase in tetracycline
resistance, however, coincided with a 72% increase in
usage of tetracycline in pigs during the same period. We
consider it likely that the increase in resistance is a
reflection of increased usage. Two S. Typhimurium
isolates from pigs had ciprofloxacin MIC values of 0.25
and 1, respectively, (Table 16) and were resistant to
nalidixic acid. According to NCCLS guidelines, these
isolates are susceptible to ciprofloxacin, however clinical
experience shows that in humans the response of such
isolates to treatment with ciprofloxacin is considerably
reduced.
Salmonella from food
In 2001, a total of 279 isolates were included in this
report, 161 isolates originated from broiler meat, 42
from beef and 76 from pork. Tables 17 and 18 show the
MIC distribution and the occurrence of resistance in S.
Enteritidis from broiler meat and in S. Typhimurium from
pork. All 18 S. Enteritidis isolates were isolated from
imported products. Eight of the 11 S. Typhimurium
isolates were from Danish pork and the remaining 3
from imported products. Due to the low number of
isolates in each food category it is not possible to
determine if there has been a change in resistance over
time.
Salmonella from humans
In 2001, 2,918 human infections with zoonotic Salmonella serotypes were registered in Denmark, an
increase from 43.3 cases per 100,000 inhabitants in
2000 to 54.5 in 2001.
Antimicrobial resistance among human S. Enteritidis
isolates remained low in 2001 (Table 19). When
comparing the isolates associated with travel abroad
with domestically acquired isolates, no difference was
detected in the level of antimicrobial resistance (Table
19).
Among S. Typhimurium isolates, however, antimicrobial
resistance was in general higher in isolates from cases
associated with travel abroad than in isolates from
domestic cases (Table 20, Figure 7). From 1996 to
1999, resistance to ampicillin, sulfonamide, tetracycline
and chloramphenicol increased among S. Typhimurium
from domestic human cases (Figure 7). These
increases are mainly explained by an increase in the
proportion of S. Typhimurium DT104 and related phage
types among the S. Typhimurium isolates. Since 1999,
the proportion of DT104 isolates among domestic S.
Typhimurium isolates has decreased. In the same
period, we have observed a significant increase in
tetracycline, sulfonamide and streptomycin resistance
among S. Typhimurium phage types other than DT104
and related phage types (DTU302, DT104a, DT104b).
From 1997 to 2001, only a few human S. Typhimurium
cases acquired domestically were resistant to nalidixic
acid. The only exception was a small increase in 1998,
due to an outbreak with a nalidixic acid resistant S.
Typhimurium DT104 strain. In contrast, nalidixic acid
resistance has increased since 1997 among isolates of
S. Typhimurium from cases with a history of travel
abroad.
DANMAP 2001
_
_______________
Table 16. Distribution of MICs and occurrence of resistance among Salmonella Typhimurium from broilers
(n=15), cattle (n=31) and pigs (n=218), Denmark
DANMAP 2001
Compound
Animal
species
2
4
Tetracycline
Poultry
20
[4.3-48.1]
73.3
6.7
Cattle
42
[24.6-60.9]
54.8
3.2
Pigs
30
[23.8-36.4]
67.0
3.2
Poultry
7
[0.2-32.0]
6.7 66.7 20.0
Cattle
10
[2.0-25.8]
16.1 38.7 35.5
Pigs
7
[3.9-11.1]
12.4 55.5 23.4
Poultry
7
[0.2-32.0]
13.3 73.3
Cattle
10
[2.0-25.8]
9.7 80.6
Pigs
4
[1.6-7.1]
7.8 81.7
Poultry
13
[1.7-40.5]
80.0
Cattle
26
[11.9-44.6]
58.1 16.1
Pigs
11
[7.2-15.9]
71.1 16.5
Poultry
0
[0.0-21.8]
73.3 26.7
Cattle
0
[0.0-11.2]
74.2 25.8
Pigs
0
[0.0-1.7]
73.9 24.8
Poultry
13
[1.7-40.5]
33.3 46.7
Cattle
42
[24.6-60.9]
54.8
3.2
41.9
Pigs
30
[24.3-36.8]
58.7 11.0
30.3
Poultry
0
[0.0-21.8]
Cattle
0
[0.0-11.2]
100
Pigs
9
[5.7-13.8]
90.8
Poultry
0
[0.0-21.8]
93.3
6.7
3.2
Chloramphenicol
Florfenicol
Ampicillin
Ceftiofur
Sulfonamide
Trimethoprim
Apramycin
Cattle
Pigs
Gentamicin
Poultry
Cattle
Spectinomycin
Streptomycin
Ciprofloxacin
Nalidixic acid
<=0.03 0.06 0.12 0.25 0.5
1
8
16
32
64
128 256 512 >512
13.3 6.7 a)
9.7 32.3
0.5
6.9 22.5
6.7
9.7
1.8
6.7
2.3
4.6
6.7
9.7
5.5
1.4
3.2
6.7
0.5
13.3
25.8
1.4
11.0
1.4
6.7
13.3
100
0
[0.0-11.2]
96.8
<1
[0.01-2.5]
99.5
0
[0.0-21.8]
100
0
[0.0-11.2]
96.8
[0.01-2.5]
98.6
Poultry
7
[0.2-32.0]
93.3
Cattle
0
[0.0-11.2]
100
92.2
9.2
0.5
3.2
0.9
0.5
6.7
Pigs
7
[4.3-11.7]
Poultry
7
[0.2-32.0]
20.0 66.7
Cattle
13
[3.6-29.8]
3.2 83.9
0.5
7.3
1.4 84.9
6.7
6.7
12.9
Pigs
13
[8.7-18.0]
0.9
0.9 11.9
Poultry
13
[1.7-40.5]
6.7 26.7 53.3
6.7
6.7
Cattle
45
[27.3-64.0]
3.2 35.5 16.1
3.2 41.9
Pigs
24
[18.4-30.1]
Poultry
0
[0.0-21.8]
Cattle
0
[0.0-11.2]
100
Pigs
0
[0.0-1.7]
96.3
Poultry
0
[0.0-21.8]
93.3
Cattle
0
[0.0-11.2]
100
Pigs
Colistin
Distribution (%) of MICs
<1
Pigs
Neomycin
% Resistant
[95% Confidence interval]
0.9 65.6
9.6
1.4
6.0 16.5
100
2.3
0.5 0.5
0.5
<1
[0.1-3.3]
93.1
Poultry
0
[0.0-21.8]
100
Cattle
0
[0.0-11.2]
100
Pigs
0
[0.0-1.7]
100
6.7
6.0
0.9
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the
highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
Farm to table
Although S. Enteritidis was the predominant serotype in
layers in Denmark, it was rare in broiler production, and
hardly isolated from other animal species. Table 21
presents a comparison of resistance among S.
Enteritidis from Danish poultry, imported broiler meat
and isolates from human cases acquired domestically
and abroad. The resistance levels among S. Enteritidis
isolates from Danish poultry (mainly layers) and
domestically acquired human cases were not
significantly different. In contrast, significantly higher
levels of nalidixic acid resistance were found in
isolates from imported broiler meat. National
estimates of sources of human salmonellosis (Annual
Report on Zoonosis in Denmark) showed that
imported poultry accounted for 7% of human Salmonella cases in 2001, while domestically produced
table eggs accounted for 29%. This is consistent with
the observed levels of nalidixic acid resistance in
domestically acquired human cases.
27
28
__
___
DANMAP 2001
DANMAP 2001
60
Poultry
Humans
Domestic a)
Pigs
Humans
Travel abroad
% resistant isolates
50
40
30
20
10
0
96 97 98 99 00 01 96 97 98 99 00 01 97 98 99 00 01 97 98 99 00 01
Ampicillin
Nalidixic acid
Sulfonamide
Tetracycline
Chloramphenicol
Figure 7. Trends in resistance to some selected antimicrobials among Salmonella
Typhimurium isolated from poultry and pigs and from human cases, Denmark
a) Includes cases where origin of infection is non-documented and may therefore include some isolates acquired
abroad but not documented as such.
Table 17. Distribution of MICs and occurrence of resistance in Salmonella Enteritidis from imported broiler
meat (n=18), Denmark
DANMAP 2001
Compound
Tetracycline
% Resistant
[95% Confidence interval]
<=0.03
0.06
0.12
0.25
0.5
1
Distribution (%) of MICs
2
4
8
16
17
[3.6-41.4]
83.3
Chloramphenicol
Florfenicol
0
0
[0.0-18.5]
[0.0-18.5]
11.1
27.8
83.3
66.7
Ampicillin
Ceftiofur
6
0
[0.1-27.3]
[0.0-18.5]
5.6
5.6
5.6
Sulfonamide
0
[0.0-18.5]
Trimethoprim
Apramycin
0
0
[0.0-18.5]
[0.0-18.5]
Gentamicin
0
[0.0-18.5]
17
0
[3.6-41.4]
[0.0-18.5]
Streptomycin
0
[0.0-18.5]
Ciprofloxacin
Nalidixic acid
Colistin
0
39
0
[0.0-18.5]
[17.3-64.3]
[0.0-18.5]
Neomycin
Spectinomycin
83.3
94.4
32
64
128
256
512 >512
16.7 a)
5.6
5.6
5.6
5.6
88.9
5.6
5.6
5.6
100
100
100
83.3
61.1
33.3
5.6
100
94.4
5.6
61.1
94.4
5.6
5.6
38.9
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
Table 18. Distribution of MICs and occurrence of resistance in Salmonella Typhimurium from pork (n=11),
Denmark
DANMAP 2001
Compound
Tetracycline
% Resistant
[95% Confidence interval]
45
[16.7-76.6]
9
9
[0.2-41.3]
[0.2-41.3]
Ampicillin
Ceftiofur
Sulfonamide
27
0
45
[6.0-61.0]
[0.0-28.5]
[16.7-76.6]
Trimethoprim
Apramycin
18
0
[2.3-51.8]
[0.0-28.5]
Gentamicin
Neomycin
0
18
[0.0-28.5]
[2.3-51.8]
Spectinomycin
Streptomycin
Ciprofloxacin
9
36
0
[0.2-41.3]
[10.9-69.2]
[0.0-28.5]
0
0
[0.0-28.5]
[0.0-28.5]
Chloramphenicol
Florfenicol
Nalidixic acid
Colistin
<=0.03
0.06
0.12
0.25
0.5
1
Distribution (%) of MICs
2
4
8
16
54.5
9.1
9.1
54.5
27.3
45.5
45.5
81.8
32
9.1
64
128 256
36.4 a)
36.4
512 >512
9.0
9.1
45.5
27.3
45.5
81.8
100
9.1
45.5
18.2
100
81.8
18.2
90.9
63.6
9.1
9.1
27.3
100
100
100
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
DANMAP 2001
_
_______________
29
Table 19. Occurrence of resistance (%) among Salmonella Enteritidis isolated
from humans by origin of infection, Denmark
DANMAP 2001
Compound
% Resistant
Travel abroad
[95% Confidence interval]
% Resistant
Domestic a)
[95% Confidence interval]
Tetracycline
Chloramphenicol
3
0
[0.7-9.9]
[0.0-4.2]
3
0
[1.7-4.5]
[0.0-0.6]
Ampicillin
Ceftiofur
Sulfonamide
1
0
1
[0.03-6.3]
[0.0-4.2]
[0.03-6.3]
1
0
1
[0.5-2.4]
[0.0-0.6]
[0.4-2.2]
Trimethoprim
Apramycin
1
0
[0.03-6.3]
[0.0-4.2]
1
<1
[0.6-2.6]
[0.04-1.2]
Gentamicin
0
[0.0-4.2]
0
[0.0-0.6]
1
0
0
8
0
86
[0.03-6.3]
[0.0-4.2]
[0.0-4.2]
[3.3-16.1]
[0.0-4.2]
<1
0
<1
5
0
598
[0.04-1.2]
[0.0-0.6]
[0.0-0.9]
[3.1-6.7]
[0.0-0.6]
Kanamycin
Spectinomycin
Streptomycin
Nalidixic acid
Colistin
Number of isolates
a) Includes cases where origin of infection is non-documented and may therefore include some isolates
acquired abroad but not documented as such
Table 20. Occurrence of resistance (%) among Salmonella Typhimurium
isolated from humans by origin of infection, Denmark
DANMAP 2001
Compound
% Resistant
Travel abroad
[95% Confidence interval]
% Resistant
Domestic a)
[95% Confidence interval]
Tetracycline
Chloramphenicol
50
39
[32.9-67.1]
[23.1-56.5]
39
15
[34.5-42.8]
[11.8-17.9]
Ampicillin
Ceftiofur
Sulfonamide
44
3
50
[27.9-61.9]
[0.1-14.5]
[32.9-67.1]
24
0
38
[20.3-27.6]
[0.0-0.7]
[33.9-42.2]
Trimethoprim
Apramycin
11
3
[3.1-26.1]
[0.1-14.5]
10
<1
[7.2-12.3]
[0.0-1.0]
3
[0.1-14.5]
<1
[0.3-2.1]
0
31
47
17
0
36
[0.0-9.7]
[16.4-48.1]
[30.4-64.5]
[6.4-32.8]
[0.0-9.7]
3
15
34
3
0
547
[1.7-4.7]
[11.8-17.9]
[30.0-38.1]
[1.7-4.7]
[0.0-0.7]
Gentamicin
Kanamycin
Spectinomycin
Streptomycin
Nalidixic acid
Colistin
Number of isolates
a) Includes cases where origin of infection is non-documented and may therefore include some isolates
acquired abroad but not documented as such
S. Dublin is the predominant Salmonella serotype in
both cattle and beef (Table 12). In humans, 0.9% of all
Salmonella infections in 2001 were caused by S.
Dublin. In 2001, 45 S. Dublin isolates from cattle were
included in this report. In general, the isolates were
susceptible to most antimicrobials. One (2%) isolate
was resistant to nalidixic acid. This level is not different
from previous years. All S. Dublin isolates from beef and
humans were susceptibel to all antimicrobials in the test
panel.
The comparison of resistance levels among S.
Typhimurium isolates from animals, pork and
domestically-acquired human cases is presented in
Table 22. The frequency of pentaresistent S.
Typhimurium DT104 in the samples has a strong
Table 21. Comparison of resistance (%)
among Salmonella Enteritidis from food
animals, imported food and human cases
acquired domestically or associated with
travel abroad, Denmark.
DANMAP 2001
Compound
Poultry
Danish
%
4
Broiler meat
Imported
%
17
3
3
Chloramphenicol
0
0
0
0
Ampicillin
Ceftiofur
4
0
6
0
1
0
1
0
Sulfonamide
Trimethoprim
0
0
0
0
1
1
1
1
Apramycin
Gentamicin
0
0
0
0
<1
0
0
0
Spectinomycin
Streptomycin
0
0
0
0
0
<1
0
0
Nalidixic acid
0
39
5
8
0
25
0
18
0
598
0
86
Tetracyclines
Colistin
Number of isolates
Humans
Domestic a)
Travel abroad
%
%
a) Includes cases where origin of infection is non-documented and may
therefore include some isolates acquired abroad but not documented as
such
30
__
influence on the resistance levels. Therefore comparison
of resistance levels among S. Typhimurium phage types
other than DT104 and related phage types (DT104b,
DTU302) from food animals, pork and domestically
acquired human cases were made; the results are
presented in Table 23. The similar levels of resistance
___
presented in Tables 22 and 23 show that pentaresistant
DT104 onlyaccountforasmallproportionofallS.
Typhimurium isolates. The observed increase in
tetracycline resistance in domestically acquired S.
Typhimurium isolates from humans is likely to be
associated with consumption of Danish pork.
Table 22. Comparison of resistance (%) among Salmonella
Typhimurium from food animals, food of Danish origin, imported
food and human cases acquired domestically or associated with
travel abroad, Denmark
DANMAP 2001
Compound
Poultry
Danish
%
Cattle
Danish
%
Pigs
Danish
%
Tetracycline
20
42
30
45
39
50
Chloramphenicol
Ampicillin
7
13
10
26
7
11
9
27
15
24
39
44
Pork
Humans
Domestic b)
Travel abroad
%
%
a)
%
0
0
0
0
0
3
13
0
42
0
30
9
45
18
38
10
50
11
Apramycin
0
0
<1
0
<1
3
Gentamicin
Spectinomycin
0
7
0
13
<1
13
0
9
<1
15
3
31
Streptomycin
13
45
24
36
34
47
Nalidixic acid
Colistin
Number of isolates
0
0
15
0
0
31
<1
0
218
0
0
11
3
0
547
17
0
36
Ceftiofur
Sulfonamide
Trimethoprim
a) 8 isolates originated from Danish pork and 3 isolates from imported pork
b) Includes cases where origin of infection is non-documented and may therefore include some
isolates acquired abroad but not documented as such.
Table 23. Comparison of resistance (%) among
Salmonella Typhimurium other than DT104,
DT104a, DT104b and DTU302 from food animals,
pork and human cases acquired domestically,
DANMAP 2001
Denmark
Compound
Poultry
Danish
%
Cattle
Danish
%
Pigs
Danish
%
14
0
36
0
27
Ampicillin
7
18
3
7
Ceftiofur
Sulfonamide
0
0
0
7
36
Tetracyclines
Chloramphenicol
Pork
Humans
a) Domestic b)
%
%
44
0
31
3
22
14
28
0
44
0
30
Trimethoprim
0
0
10
11
10
Apramycin
Gentamicin
0
0
0
0
0
0
0
0
0
<1
Spectinomycin
0
4
10
0
3
Streptomycin
7
39
20
33
26
0
0
14
0
0
28
1
0
205
0
0
9
2
0
468
Nalidixic acid
Colistin
Number of isolates
a) 7 isolates originated from Danish pork and 2 isolates from imported
pork
b) Includes cases where origin of infection is non-documented and may
therefore include some isolates acquired abroad but not documented as
such.
DANMAP 2001
DANMAP 2001
_
_______________
Campylobacter
With 86.4 cases per 100,000 inhabitants,
campylobacteriosis is the most common foodborne
zoonosis in Denmark. Campylobacter jejuni is
estimated to be responsible for 90-95% of all human
Campylobacter infections while C. coli is the second
most common species. Approximately 80% of the human
cases are acquired in Denmark.
Campylobacter from food animals
Tables 24 and 25 present the MIC distributions and
occurrence of antimicrobial resistance among C. jejuni
from cattle and broilers and C. coli from pigs and broilers
in 2001. Trends in resistance to selected antimicrobials
among C. jejuni and C. coli during 1996-2001 are
presented in Figures 8 and 9, respectively. Among
Campylobacter spp., resistance to nalidixic acid often
results in simultaneous resistance to ciprofloxacin. In
2001 the breakpoint for ciprofloxacin was adjusted from
>1 to >2 (Table A1). Applying this breakpoint
retrospectively did not alter the proportion of resistant
isolates from 1997-2001 (Figures 8 and 9).
Nalidixic acid resistance was still low in C. jejuni from
broilers; however, the steady increase observed during
the past years is a cause for concern (Figure 8). In
contrast, resistance to nalidixic acid decreased from
17% to 5% in C. coli from pigs between 1998 and 2001
(Figure 9). This decrease coincided with withdrawal from
the market of an oral fluoroquinolone formulation for
pigs.
Macrolide resistance in C. coli from pigs has remained
at a high level in 2000 and 2001 (Figure 9). The macrolide tylosin was the most widely used antimicrobial
growth promoter (AGP) in the pig production until 1999
where all AGPs were withdrawn. However, macrolides
are still used for treatment of infections in pigs. In 2000
and 2001, 8,900 kg and 10,835 kg tylosin, respectively
were used for this indication. Because C. coli is rarely
isolated from broilers (only 12 isolates in 2001), it is
difficult to analyse trends in resistance for this bacteria.
Nevertheless, erythromycin resistance in C. coli
remained at a relatively high level during 1996-2001.
This is probably due to the use of the AGP virginiamycin
until 1998 (Figure 9).
Campylobacter from food
Campylobacter spp. were isolated from Danish and
imported poultry meat samples collected at retail outlets.
A new semi-quantitative method for the analysis of
thermophilic Campylobacter spp. in foods was
introduced in 2000 (Appendix 1). In 2001, the
prevalence of thermophilic Campylobacter spp. was
35.3% (387/1,096) in raw broiler meat and 22.1% (177/
800) in raw turkey meat (Annual Report on Zoonosis in
Denmark 2001). Among these, a random subsample of
Table 24. Distribution of MICs and occurrence of resistance among Campylobacter jejuni from
broilers (n=79 isolates) and cattle (n=38 isolates), Denmark
DANMAP 2001
Compound
Animal
species
Tetracycline
Broilers
Chloramphenicol
Sulfonamide
% Resistant
[95% Confidence Interval]
Distribution (%) of MICs
0.03 0.06 0.125 0.25
0.5
1
2
2.5
1.3
2.6
5.3
4
8
16
32
64
128 256
1
[0.03-6.9]
94.9
Cattle
8
[1.7-21.4]
81.6
Broilers
0
[0.0-4.6]
8.9 67.1 20.3
Cattle
8
[1.7-21.4]
71.1 18.4
Broilers
0
[0.0-4.6]
25.3 31.6 24.1
11.4
6.3
Cattle
0
[0.0-9.3]
39.5 10.5 21.1
23.7
5.3
Broilers
0 b)
[0.0-4.6]
Cattle
8
[1.7-21.4]
2.6 31.6 44.7 13.2
Gentamicin
Broilers
0
[0.0-4.6]
67.1 30.4
2.5
Cattle
0
[0.0-9.3]
44.7 52.6
2.6
Neomycin
Broilers
0
[0.0-4.6]
43.0 49.4
7.6
Cattle
0
[0.0-9.3]
31.6 57.9
7.9
Broilers
3
[0.3-8.9]
7.6 68.4 21.5
Cattle
13
[4.4-28.1]
5.3 60.5 21.1
Broilers
6
[2.1-14.2]
Cattle
8
[1.7-21.4]
Broilers
8
[2.8-15.8]
1.3 24.1 64.6
2.5
Cattle
8
[1.7-21.4]
18.4 60.5
7.9
Erythromycin
Streptomycin
Ciprofloxacin
Nalidixic acid
Colistin
11.5 25.6 55.1
2.5
31
1.3 58.2 30.4
5.1
2.6
2.6
2.6
2.6
3.8
2.6
7.9
1.3
2.6
7.9
2.6
1.3
2.6 52.6 36.8
512 1024
1.3 a)
2.5
5.3
1.3
2.6
7.9
5.1
5.3
2.5
5.3
Broilers
0
[0.0-4.6]
2.5
1.3
7.6 19.0 38.0 29.1
2.5
Cattle
0
[0.0-9.3]
7.9
5.3 15.8 10.5 39.5 15.8
5.3
2.6
3.8
1.3
5.3
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the
highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
b) Only 78 isolates were tested against erythromycin.
32
__
___
DANMAP 2001
Table 25. Distribution of MICs and occurrence of resistance among Campylobacter coli from
broilers (n=12 isolates) and pigs (n=94 isolates), Denmark
DANMAP 2001
Compound
Animal
% Resistant
species [95% Confidence Interval]
0.03 0.06 0.125 0.25
0.5
1
Distribution (%) of MICs
2
4
8
16 32
64
Tetracycline
Broilers
0 a)
[0.0-28.5]
100 b)
Pigs
1
[0.03-5.8]
88.3
Chloramphenicol
Broilers
0
[0.0-26.5]
50.0 50.0
Pigs
1
[0.03-5.8]
7.4 24.5 48.9 12.8
5.3
1.1
Sulfonamide
Broilers
0
[0.0-26.5]
33.3 33.3 25.0
8.3
Pigs
1 c)
[0.03-5.9]
44.1 31.2 11.8
Erythromycin
Broilers
27 a)
[6.0-61.0]
Pigs
30
[20.8-40.1]
Gentamicin
Broilers
0
[0.0-26.5]
33.3 58.3
Pigs
0
[0.0-3.9]
13.8 51.1 34.0 1.1
Neomycin
Broilers
0
[0.0-26.5]
33.3 50.0 16.7
Pigs
0
[0.0-3.9]
6.4 34.0 54.3
Broilers
17
[2.1-48.4]
8.3 41.7 33.3
Pigs
48
[37.5-58.4]
1.1 12.8 26.6 11.7
1.1
5.3
Ciprofloxacin
Broilers
0
[0.0-26.5]
8.3
Pigs
5
[1.8-12.0]
3.2 10.6 31.9 29.8 11.7
3.2
3.2
1.1
Nalidixic acid
Broilers
0 a)
[0.0-28.5]
Pigs
5 c)
[1.8-12.1]
Colistin
Broilers
0
[0.0-26.5]
16.7
Pigs
1
[0.03-5.8]
27.7 31.9 14.9 16.0
Streptomycin
9.1
5.3
8.3
6.4
3.2
1.1
1.1
45.5 18.2
9.7
2.2
1.1
27.3
7.4 13.8 18.1 16.0
33.3 41.7
128 256 512 1024
8.5
1.1
29.8
8.3
5.3
16.7
5.3
36.2
4.3
1.1
8.3
4.3
1.1
9.1 81.8 9.1
2.2
4.3
9.7 48.4 22.6
8.3 33.3 8.3 16.7
3.2
7.5
8.3
8.3
4.3
1.1
1.1
Lines indicate breakpoints for resistance
a) Only 11 isolates were tested against tetracycline, erythromycin and nalidixic acid.
b) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the
highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
c) Only 93 isolates were tested against sulfamethoxazole and nalidixic acid.
DANMAP 2001
C. jejuni
(broilers)
% resistant isolates
30
C. jejuni
(cattle)
C. jejuni
(human domestic cases)
20
10
0
96
97
98
99
00
01
96
Erythromycin
Streptomycin
97
98
99
00
01
97
Nalidixic acid
Ciprofloxacin
98
99
00
01
Tetracycline
Figure 8. Trends in resistance to selected antimicrobials among Campylobacter jejuni from broilers, cattle
and human domestic cases, Denmark
C. coli
(pigs)
% resistant isolates
80
DANMAP 2001
C. coli
(broilers)
60
40
20
0
96
97
98
99
Erythromycin
Sulfonamide
00
01
96
97
Nalidixic acid
Tetracycline
98
99
00
01
Streptomycin
Figure 9. Trends in resistance to selected antimicrobials among Campylobacter coli from pigs and broilers,
Denmark
DANMAP 2001
_
_______________
33
frequency of this species in human Campylobacter
infections as compared to C. jejuni.
117 C. jejuni isolates from broiler and turkey meat was
tested for antimicrobial susceptibility.
Table 26 presents the MIC distributions and occurrence
of antimicrobial resistance among C. jejuni from broiler
and turkey meat samples in 2001. Resistance to
tetracycline was significantly higher in isolates from
turkey meat than from broiler meat.
Farm to table
A comparison of resistance levels among C. jejuni from
Danish food animals, food of Danish and imported
origin and domestically acquired human cases are
presented in Table 27. In general the resistance levels
were comparable. The exception was a significantly
lower level of tetracycline resistance in C. jejuni from
broilers and Danish broiler meat compared to C. jejuni
from domestically acquired human cases.
Epidemiological studies have shown that broilers/broiler
meat are important host risk factors for C. jejuni
infections in humans but also that previous antibiotic
treatment was a risk factor. Thus, humans taking
antibiotics are more likely to get Campylobacter
infections. This and infections aquired from imported
broiler products may influence the occurrence of
resistance among Campylobacter isolates from
humans.
Campylobacter from humans
Resistance in C. jejuni from human clinical samples
stratified among domestic and travel-associated cases
is presented in Table 27. Resistance to tetracycline and
quinolones was higher among C. jejuni associated with
travel. Additionally, 5-year trends in resistance to
selected antimicrobials among human C. jejuni isolates
acquired in Denmark are presented in Figure 8. This
analysis showed that the increase in tetracycline and
quinolone resistance observed seems to have levelled
out in 2001. Resistance data on C. coli isolated from
humans are not presented because of the much lower
Table 26. Distribution of MICs and occurrence of resistance among Campylobacter jejuni from broiler meat
(n=74 isolates) and turkey meat (n=43 isolates), Denmark
DANMAP 2001
Compound
Food type
% Resistant
[95% Confidence Interval]
Distribution (%) of MICs
Tetracycline
Broiler meat
Turkey meat
3
26
[0.3-9.4]
[13.5-41.2]
0.5
86.5
69.8
Erythromycin
Broiler meat
Turkey meat
1
2 b)
[0.0-7.3]
[0.1-12.9]
24.3
34.1
Gentamicin
Broiler meat
Turkey meat
0
0
[0.0-4.9]
[0.0-8.2]
86.5 12.2
76.7 20.9
Streptomycin
Broiler meat
Turkey meat
7
7
[2.2-15.1]
[1.5-19.1]
Ciprofloxacin
Broiler meat
Turkey meat
11
0
[4.8-20.2]
[0.0-8.2]
Broiler meat
Turkey meat
11
0
[4.8-20.2]
[0.0-8.2]
Nalidixic acid
<=0.03 0.06 0.12
81.1
90.7
2.7
2.7
4.7
0.25
1.4
2.3
1
1.4
4.7
2
5.4
4
8
4.1
16
6.8
20.3 18.9 25.7
4.9 41.5 14.6
2.7
2.4
1.4
4.1
1.4
1.4
7.0
1.4
8.1
2.3
32
64 128
1.4 1.4 a)
7.0 16.3
256
512
>512
2.4
1.4
2.3
79.7 5.4
79.1 14.0
2.7
5.4
1.4
8.1
2.7
5.4
37.8 13.5
25.6 32.6
1.4
4.7
2.3
29.7
37.2
1.4
1.4
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
b) Only 41 isolates from turkey meat were tested against erythromycin.
Table 27. Resistance (%) among Campylobacter jejuni from Danish food
animals, food of Danish origin and imported food, and human cases acquired
domestically or associated with travel
DANMAP 2001
Compound
Cattle Broilers
Broiler meat
Danish Danish Danish Imported
%
%
%
%
Turkey meat
Danish Imported
%
%
Humans
Travel
Domestic
% associated
%
25
33
10
7
7
0
21 c)
20 c)
13
0
21
53
22
53
72
15
Tetracycline
8
1
2
8
16
39
Chloramphenicol
8
0
NT a)
NT a)
NT a)
NT a)
Erythromycin
8
0
2
0
0 b)
6
Gentamicin
0
0
0
0
0
0
Streptomycin
13
3
8
0
8
6
Ciprofloxacin
8
6
13
0
0
0
Nalidixic acid
8
8
13
0
0
0
Number of isolates
38
79
61
13
25
18
a) NT, not tested.
b) Only 23 isolates were tested against erythromycin.
c) Resistance to gentamicin in these isolates may be attributable to a methodological problem as indicated by
evaluation of population histograms. This problem had no impact on susceptibility to other antimicrobials.
34
__
___
DANMAP 2001
Resistance in indicator bacteria
The MIC distribution and the occurrence of resistance
among enterococci are shown in Tables 28 and 29.
Enterococci from food animals
The indicator bacteria from food animals were isolated
from faecal samples from cattle and pigs and cloacal
swabs from broilers. The samples were collected at
slaughter.
Among Enterococcus faecium from broilers,
virginiamycin resistance decreased from 39.2% in 1999
Table 28. Distribution of MICs and occurrence of resistance among Enterococcus faecium from
DANMAP 2001
broilers (n=131), cattle (n=18) and pigs (n=175), Denmark
Compound
Tetracycline
Chloramphenicol
Animal
species
Broilers
Penicillin
Gentamicin
Kanamycin
[1.4-34.7]
88.9
46.9 0.6
0
[0.0-2.8]
0
[0.0-18.5]
33.3 66.7
<1
[0.01-3.1]
2.9 29.7 66.3
Broilers
0
[0.0-2.8]
34.4 65.6
Cattle
0
[0.0-18.5]
22.2 77.8
Pigs
0
[0.0-2.1]
38.3 61.7
57
[48.3-65.9]
29.8
0
[0.0-18.5]
55.6 27.8 16.7
Pigs
36
[28.9-43.6]
Broilers
15
[9.6-22.6]
76.3 5.3
Cattle
11
[1.4-34.7]
27.8 44.4 16.7 11.1
Pigs
20.0 30.3 23.4
Broilers
0.8
512 1024 2048 >2048
0.8 a)
5.6
5.6
1.7
5.7
44.6
0.6
0.6
9.2 32.8 58.0
6.9
6.1
9.9 46.6
28.6 25.1 10.3 34.3
3.1
2.3
2.3
1.7
2.3
8.4
0.6
23.4
[19.9-33.5]
0
[0.0-2.8]
Cattle
0
[0.0-18.5]
100
Pigs
0
[0.0-2.1]
99.4
<1
[0.02-4.2]
26.7 60.3
9.2
3.1
0
[0.0-18.5]
38.9 50.0
5.6
5.6
Pigs
16
[10.9-22.3]
35.4 37.7 10.3
0.6
Broilers
<1
[0.02-4.2]
98.5
0
[0.0-18.5]
88.9 11.1
Broilers
2.3
0.8
26
100
18
[12.9-24.8]
Broilers
3
[0.8-7.6]
91.6 3.8
Cattle
0
[0.0-18.5]
66.7 33.3
Pigs
3
[1.3-7.3]
Broilers
27
[20.1-36.0]
25.2 39.7 4.6
3.1 25.2
Cattle
0 b)
[0.0-19.5]
29.4 58.8 5.9
5.9
6
[3.2-11.0]
21.7 41.7 23.4
6.9
6.3
31
[22.8-39.2]
19.8 22.9 26.7 22.9
6.9
Cattle
6
[0.1-27.3]
22.2 11.1 61.1
5.6
Pigs
9
[4.9-13.7]
21.7
6.3
2.3
Broilers
5
[2.2-10.7]
19.8 29.0 38.2
7.6
4.6
Cattle
0
[0.0-18.5]
5.6 61.1 33.3
9.9
3.1
80.6 12.0
9.7 60.0
0.6
3.4
78
[52.4-93.6]
Pigs
63
[55.8-70.6]
Broilers
11
[6.6-18.2]
0
[0.0-18.5]
100
12.2
Cattle
0
[0.0-18.5]
77.8 22.2
Pigs
0
[0.0-2.1]
88.6 10.9
74.3
2.3
2.3
16.0
5.3 62.6
2.9
9.1
9.1
9.1
13.7
[0.0-2.8]
0.8
0.8
Cattle
[6.7-16.4]
14.9
0.8
[0.0-2.1]
0
1.1
0.8
3.4
[76.6-89.8]
11
0.8
2.3
0
Broilers
0.6
3.1
84
Pigs
17.7 73.1
1.5
Broilers
Cattle
Salinomycin
Distribution (%) of MICs
16 32
64
128 256
Broilers
Pigs
Nitrofurantoin
0.6
Cattle
Quinupristin/dalfopristin Broilers
Bacitracin
8
Broilers
Pigs
Avilamycin
4
0.8
[44.3-59.6]
Pigs
Virginiamycin
97.7
11
Cattle
Vancomycin
[0.5-6.6]
2
52
Cattle
Streptomycin
1
Cattle
Cattle
Erythromycin
2
<=0.5
Pigs
Pigs
Florfenicol
% Resistant
[95% Confidence interval]
2.3
2.3
0.8
5.6
16.7
44.4 16.7 16.7
3.4
17.1
30.9 14.3 18.3
88.5
11.5
89.1
10.9
16.8 71.0
0.6
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the
highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
b) n=17 isolates
DANMAP 2001
_
_______________
In 2000, an E. faecium clone resistant to erythromycin,
kanamycin, streptomycin, quinupristin/dalfopristin,
virginiamycin and tetracycline emerged among isolates
from cattle. In 2001, only 18 E. faecium isolates were
collected from cattle compared to 48 isolates in 2000
and none of the 18 isolates shared this specific
resistance profile.
to 27.7% in 2001 (Figure 10). In 2001, the combination
of resistance to penicillin and streptogramin was still
prevalent among E. faecium from broilers, while only a
few isolates had the macrolide/streptogramin resistance
combination. Virginiamycin has not been used in
Denmark since January 1998. Instead, it is possible that
the use of penicillin for treatment of disease has
selected for penicillin/streptogramin resistant isolates so
that virginiamycin resistance remained at a high level.
Data from the VetStat programme showed that penicillin
was the most common antimicrobial used for treatment
of broilers in Denmark in 2001.
The resistance profile was also observed in pigs in
2000. In 2001, it was still present in pigs but had
become less prevalent. The result has been a significant
decrease in resistance to virginiamycin, erythromycin
(figures 13 and 14), nitrofurantoin, quinupristin/
dalfopristin and tetracycline among E. faecium from pigs
from 2000 to 2001. The reason why the specific
resistance profile is less prevalent in pigs, and perhaps
also in cattle, in 2001 compared to 2000 is not known.
From 2000 to 2001, resistance to vancomycin
(avoparcin) among E. faecium from broilers and pigs
has remained unchanged (Figure 15).
After the withdrawal of antimicrobial growth promoters,
the occurrence of resistance to avoparcin and
avilamycin has decreased markedly among E. faecium
from broilers and has remained at the same low level
from 2000 to 2001 (Figures 11 and 12). Resistance to
bacitracin has remained unchanged at >80% in broilers
and >50% in pigs despite the withdrawal.
Table 29. Distribution of MICs and occurrence of resistance among Enterococcus faecalis from
broilers (n=82) and pigs (n=184), Denmark
DANMAP 2001
Compound
Animal
species
% Resistant
[95% Confidence interval]
Tetracycline
Broilers
43
[31.8-54.1]
57.3
Pigs
85
[78.8-89.6]
14.1
Chloramphenicol
Broilers
1
[0.03-6.6]
Pigs
3
[1.2-7.0]
Florfenicol
Broilers
0
[0.0-4.4]
69.5 30.5
Pigs
0
[0.0-2.0]
23.4 76.1
0.5
Penicillin
Broilers
0
[0.0-4.4]
78.0 20.7
1.2
Pigs
0
[0.0-2.0]
38.0 62.0
Broilers
22
[13.6-32.5]
35.4 40.2
2.4
Pigs
32
[25.4-39.3]
59.8
0.5
Distribution (%) of MICs
<=0.5
Erythromycin
Gentamicin
1
2
4
8
16
32
7.3
8.5 26.8 a)
1.1 11.4 16.8
4.9 57.3 36.6
8.7 81.5
7.6
3.7
64
128
256
512 1024 2048 >2048
56.5
1.2
6.5
7.3
2.2
2.4
1.1
8.5
32.1
Broilers
0
[0.0-4.4]
100
Pigs
3
[1.2-7.0]
96.7
Kanamycin
Broilers
0
[0.0-4.4]
92.7
7.3
Pigs
14
[9.4-20.0]
84.2
1.1
Streptomycin
Broilers
6
[2.0-13.7]
91.5
2.4
Pigs
29
[22.4-35.9]
57.6 13.0
Vancomycin
2.2
0.5
0
[0.0-4.4]
81.7 18.3
Pigs
0
[0.0-2.0]
75.5 23.4
Avilamycin
Broilers
0
[0.0-4.4]
31.7 68.3
Pigs
1
[0.1-3.9]
28.3 68.5
Bacitracin
Broilers
63
[52.1-73.8]
8.5
4.9
6.1
17.1
23.2
4.9 35.4
Pigs
40
[32.6-47.1]
2.7
7.6 15.8
34.2
29.9
7.1
Flavomycin
Broilers
11
[5.1-19.8]
2.4 29.3 53.7
3.7
Pigs
<1
[0.01-3.0]
21.2 66.3 10.9
1.1
Nitrofurantoin
Broilers
1
[0.03-6.6]
98.8
Pigs
0
[0.0-2.0]
100
Broilers
0
[0.0-4.4]
69.5
6.1 24.4
Pigs
0
[0.0-2.0]
93.5
6.5
1.1
14.1
0.5
Broilers
Salinomycin
35
1.2
4.9
1.6
27.2
1.1
2.2
1.1
2.7
11.0
0.5
1.2
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the
highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
36
__
___
DANMAP 2001
12,000
80
10,000
8,000
60
6,000
40
4,000
20
2,000
0
Kg active compound
% resistant isolates
DANMAP 2001
100
0
1994
1995
1996
1997
1998
1999
2000
2001
Period
Virginiamycin
Broilers
Broiler meat
Figure 10. Trend in virginiamycin resistance among Enterococcus faecium from broilers and broiler meat
and the usage of the growth promoter virginiamycin, Denmark
% resistant isolates
30,000
25,000
80
20,000
60
15,000
40
10,000
20
5,000
0
Kg active compound
DANMAP 2001
100
0
1994
1995
1996
1997
1998
1999
2000
2001
Period
Avoparcin
Broilers
Broiler meat
Figure 11. Trend in avoparcin resistance among Enterococcus faecium from broilers and broiler meat and
the usage of the growth promoter avoparcin, Denmark
3,000
80
2,500
2,000
60
1,500
40
1,000
20
500
0
Kg active compound
% resistant isolates
DANMAP 2001
100
0
1994
1995
1996
1997
1998
1999
2000
2001
Period
Avilamycin
Broilers
Broiler meat
Figure 12. Trend in avilamycin resistance among Enterococcus faecium from broilers and broiler meat and
the usage of the growth promoter avilamycin, Denmark
DANMAP 2001
_
_______________
37
DANMAP 2001
% resistant isolates
10,000
80
8,000
60
6,000
40
4,000
20
2,000
0
Kg active compound
12,000
100
0
1994
1995
1996
1997
1998
1999
2000
2001
Period
Virginiamycin
Pigs
Pork
Figure 13. Trend in virginiamycin resistance among Enterococcus faecium from pigs and pork and the
usage of the growth promoter virginiamycin, Denmark
DANMAP 2001
100
80,000
60,000
50,000
60
40,000
40
30,000
20,000
20
Kg active compound
% resistant Isolates
70,000
80
10,000
0
0
1994
1995
1996
1997
1998
1999
2000
2001
Period
Macrolides
Pigs
Pork
Figure 14. Trend in erythromycin resistance among Enterococcus faecium from pigs and pork and the total
usage of macrolides, both as growth promoters and therapeutics, Denmark
DANMAP 2001
30,000
25,000
80
20,000
60
15,000
40
10,000
20
5,000
0
Kg active compound
% resistant isolates
100
0
1994
1995
1996
1997
1998
1999
2000
2001
Period
Avoparcin
Pigs
Pork
Figure 15. Trend in avoparcin resistance among Enterococcus faecium from pigs and pork and the usage of
the growth promoter avoparcin, Denmark
38
__
___
DANMAP 2001
Table 30. Distribution of MICs and occurrence of resistance among Enterococcus faecium from turkey
meat (n=21), broiler meat (n=44), beef (n=45) and pork (n=16), Denmark
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Penicillin
Erythromycin
Gentamicin
Kanamycin
Streptomycin
Vancomycin
Virginiamycin
Quinupristin/dalfopristin
Avilamycin
Bacitracin
Nitrofurantoin
Salinomycin
Food type
% Resistant
[95% Confidence interval]
<=0.5
2
4.8
2.3
4
8
Distribution (%) of MICs
16
32
64
128
9.5 33.3 a)
Turkey meat
43
[21.8-66.0]
1
52.4
Broiler meat
41
[26.3-56.8]
56.8
Beef
18
[8.0-32.1]
77.8
Pork
13
[1.6-38.4]
87.5
Turkey meat
Broiler meat
0
0
[0.0-16.1]
[0.0-8.0]
38.1
40.9
33.3
43.2
9.5
9.1
19.0
6.8
Beef
0
[0.0-7.9]
31.1
46.7
17.8
4.4
Pork
0
[0.0-20.6]
56.3
37.5
Turkey meat
0
[0.0-16.1]
85.7
14.3
Broiler meat
Beef
0
0
[0.0-8.0}
[0.0-7.9]
90.9
100
9.1
4.4
4.5
6.8
2.2
6.7
256
512
1024
2048
>2048
29.5
8.9
12.5
6.3
Pork
0
[0.0-20.6]
93.8
6.3
Turkey meat
0
[0.0-16.1]
81.0
19.0
Broiler meat
7
[1.4-18.7]
61.4
15.9
Beef
0
[0.0-7.9]
88.9
11.1
Pork
Turkey meat
0
71
[0.0-20.6]
[47.8-88.7]
4.8
93.8
9.5
6.3
14.3
38.1
Broiler meat
30
[16.8-45.2]
47.7
15.9
6.8
11.4
2.3
4.5
11.4
Beef
22
[11.2-37.1]
37.8
22.2
17.8
13.3
2.2
2.2
4.4
Pork
19
[4.1-45.7]
62.5
6.3
12.5
12.5
Turkey meat
Broiler meat
0
0
[0.0-16.1]
[0.0-8.0]
100
100
Beef
0
[0.0-7.9]
100
Pork
0
[0.0-20.6]
100
Turkey meat
14
[3.1-36.3]
47.6
33.3
4.8
14.3
Broiler meat
Beef
2
0
[0.1-12.0]
[0.0-7.9]
63.6
60.0
29.5
26.7
4.5
13.3
2.3
31.3
15.9
6.8
33.3
6.3
Pork
0
[0.0-20.6]
68.8
Turkey meat
14
[3.1-36.3]
81.0
Broiler meat
2
[0.1-12.0]
95.5
2.3
Beef
Pork
9
0
[2.5-21.2]
[0.0-20.6]
86.7
93.8
4.4
Turkey meat
0
[0.0-16.1]
100
Broiler meat
5
[0.6-15.5]
81.8
13.6
Beef
0
[0.0-7.9]
93.3
6.7
Pork
Turkey meat
0
10
[0.0-20.6]
[1.2-30.4]
33.3
68.8
42.9
31.3
14.3
Broiler meat
5
[0.6-15.5]
45.5
31.8
11.4
6.8
Beef
4
[0.5-15.2]
55.6
22.2
11.1
6.7
4.4
Pork
13
[1.6-38.4]
18.8
56.3
6.3
6.3
12.5
Turkey meat
14
[3.1-36.3]
9.5
38.1
38.1
Broiler meat
Beef
9
16
[2.5-21.7]
[6.5-29.5]
38.6
40.0
20.5
15.6
31.8
28.9
4.5
11.1
2.3
2.2
25.0
6.3
6.3
2.3
4.8
9.5
2.3
6.7
6.3
4.5
4.8
2.3
4.8
2.3
4.8
9.5
2.3
2.2
Pork
13
[1.6-38.4]
12.5
50.0
Turkey meat
14
[3.1-36.3]
28.6
57.1
Broiler meat
9
[2.5-21.7]
29.5
52.3
6.8
Beef
Pork
0
0
[0.0-7.9]
[0.0-20.6]
48.9
68.8
46.7
31.3
4.4
Turkey meat
29
[11.3-52.2]
19.0
4.8
19.0
28.6
Broiler meat
43
[28.4-59.0]
20.5
9.1
11.4
15.9
4.5
Beef
18
[8.0-32.1]
31.1
8.9
13.3
28.9
13.3
Pork
Turkey meat
6
0
[0.2-30.2]
[0.0-16.1]
37.5 12.5 18.8
25.0
100
Broiler meat
0
[0.0-8.0]
100
Beef
0
[0.0-7.9]
100
Pork
0
[0.0-20.6]
Turkey meat
Broiler meat
0
0
[0.0-16.1]
[0.0-8.0]
71.4
50.0
Beef
Pork
0
0
[0.0-7.9]
[0.0-20.6]
100
100
14.3
9.1
28.6
4.5
34.1
4.4
6.3
100
14.3
9.1
14.3
36.4
4.8
4.5
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest
concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
2.2
DANMAP 2001
_
_______________
Table 31. Distribution of MICs and occurrence of resistance among Enterococcus faecalis from turkey
meat (n=21), broiler meat (n=22), beef (n=32) and pork (n=33), Denmark
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Penicillin
Erythromycin
Gentamicin
Kanamycin
Streptomycin
Vancomycin
Avilamycin
Bacitracin
Flavomycin
Nitrofurantoin
Salinomycin
Food type
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
Turkey meat
Broiler meat
Beef
Pork
% Resistant
[95% Confidence interval]
57
41
16
24
10
0
0
3
0
0
0
0
0
0
0
0
29
32
6
9
0
0
0
0
0
0
3
3
19
14
6
6
0
0
0
0
5
0
0
0
19
18
6
6
5
5
3
3
0
0
0
0
0
0
0
0
[34.0-78.1]
[20.7-63.7]
[5.2-32.8]
[11.1-42.2]
[1.6-30.4]
[0.0-15.4]
[0.0-10.9]
0.1-15.8
[0.0-16.1]
[0.0-15.4]
[0.0-10.9]
[0.0-10.6]
[0.0-16.1]
[0.0-15.4]
[0.0-10.9]
[0.0-10.6]
[11.2-52.2]
[13.9-54.9]
[0.8-20.8]
[1.9-24.3]
[0.0-16.1]
[0.0-15.4]
[0.0-10.9]
[0.0-10.6]
[0.0-16.1]
[0.0-15.4]
[0.1-16.2]
[0.1-15.8]
[5.5-41.9]
[2.9-34.9]
[0.8-20.8]
[0.8-20.2]
[0.0-16.1]
[0.0-15.4]
[0.0-10.9]
[0.0-10.6]
[0.1-23.9]
[0.0-15.4]
[0.0-10.9]
[0.0-10.6]
[5.5-41.9]
[5.2-40.3]
[0.8-20.8]
[0.8-20.2]
[0.1-23.8]
[0.1-22.8]
[0.1-16.2]
[0.1-15.8]
[0.0-16.1]
[0.0-15.4]
[0.0-10.9]
[0.0-10.6]
[0.0-16.1]
[0.0-15.4]
[0.0-10.9]
[0.0-10.6]
<=0.5
1
2
38.1
45.5 13.6
81.3
75.8
14.3
22.7
15.6
30.3
71.4
86.4
90.6
87.9
90.5
95.5
75.0
84.8
47.6 23.8
45.5 22.7
56.3 34.4
57.6 33.3
4
8
Distribution (%) of MICs
16
32
64
128 256
4.8 4.8 47.6 a)
4.5 13.6 22.7
3.1 3.1
12.5
9.1 15.2
29.1
9.5
22.7
18.8
27.3
3.0
47.1
54.5
65.6
39.4
28.6
13.6
9.4
12.1
9.5
4.5
21.9 3.1
15.2
28.6
13.6
3.1
9.1
18.2
3.1
3.1
100
100
100
100
100
100
96.9
97.0
76.2
86.4
87.5
93.9
47.6
77.3
71.9
69.7
47.6
59.1
56.3
51.5
52.4
22.7
25.0 3.1
30.3
47.6
40.9
43.8
45.5 3.0
42.9
18.2
37.5
36.4
42.9
22.7
9.4 6.3
12.1 6.1
4.8
4.5
3.1 3.1
3.1
3.0
19.0
9.1
6.3
6.1
4.8
52.4
54.5
68.8
81.8
9.5
54.5
43.8
42.4
512 1024 2048 >2048
4.8
19.0
18.2
12.5
6.1
9.5
9.1
12.5
3.0
3.0
4.8
19.0
18.2
6.3
6.1
4.5
3.1
3.0
100
100
100
100
100
77.3 18.2 4.5
90.6 6.3 3.1
100
Lines indicate breakpoints of resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest
concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
39
40
__
___
DANMAP 2001
Table 32. Occurrence of resistance (%) among Enterococcus faecium from food
animals and foods of Danish and imported origin
DANMAP 2001
Compound
Pigs
Danish
%
Pork
Danish
%
Cattle
Danish
%
Beef
Danish Imported
%
%
Broilers
Danish
%
Broiler meat
Danish
Imported
%
%
Tetracycline
52
13
11
20
15
2
20
68
Chloramphenicol
Florfenicol
<1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Penicillin
Erythromycin
36
26
0
19
0
11
0
28
0
15
57
15
8
32
5
26
0
0
0
0
0
0
0
0
Kanamycin
Streptomycin
Gentamicin
16
18
0
0
0
0
0
16
0
0
<1
<1
0
0
5
5
Vancomycin
Virginiamycin
3
6
0
13
0
0
0
4
0
5
3
27
4
4
5
5
Quinupristin/dalfopristin
9
13
6
20
10
31
12
5
0
63
0
6
0
78
0
20
0
15
5
84
4
44
16
42
11
0
176
0
0
16
0
0
18
0
0
25
0
0
20
11
0
131
0
0
25
0
0
19
Avilamycin
Bacitracin
Nitrofurantoin
Salinomycin
Number of isolates
Table 33. Occurrence of resistance (%) among
Enterococcus faecalis from food animals and foods
of Danish origin
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Penicillin
Erythromycin
Gentamicin
Pigs
Danish
%
Pork
Danish
%
Broilers
Danish
%
Broiler meat
Danish
%
85
23
43
40
3
0
3
0
1
0
0
0
0
0
0
0
32
10
22
33
3
0
0
0
Kanamycin
Streptomycin
14
29
3
6
0
6
0
20
Vancomycin
0
0
0
0
Avilamycin
1
0
0
0
Bacitracin
40
6
63
20
Flavomycin
Nitrofurantoin
<1
0
3
0
11
1
7
0
0
184
0
31
0
82
0
15
Salinomycin
Number of isolates
Among E. faecalis isolates from broilers we saw no
significant changes in 2001 compared to 2000, whereas
among E. faecalis isolates from pigs there was a
significant increase in the proportion of isolates resistant
to bacitracin. It should be noted that most of the failures
in the performance test were in testing susceptibility of
enterococci to bacitracin.
Enterococci from food
The examination of samples from broiler meat, turkey
meat, beef and pork at retail outlets resulted in 126
isolates of E. faecium and 108 isolates of E. faecalis.
Resistance towards tetracycline, macrolides, streptomy-
cin and bacitracin were most frequent.
The MIC distribution and the occurrence of resistance
are shown in Tables 30 and 31. Three out of 44 isolates
of E. faecium from broiler meat (7%) exhibited penicillin
resistance.
Vancomycin resistance was observed in two E. faecium
isolates from broiler meat, one originated from a Danish
product and one from an imported broiler meat product.
Enterococci from farm to table
The trends in resistance presented in Figures 10-15
showed that after the withdrawal of growth promoters a
decrease in resistance to avoparcin, avilamycin,
erythromycin and virginiamycin was observed among E.
faecium from animals and some categories of meat
products.
A comparison of resistance among enterococci from
Danish food animals and foods of Danish and imported
origin are presented in Tables 32 and 33. The
occurrence of resistance in E. faecium from cattle/beef
seems to be comparable except for bacitracin. However,
in the comparison of pigs/pork and broilers/broiler meat
different resistance levels were found for tetracycline,
penicillin and bacitracin. In previous years, differences
between pigs/pork and broilers/broiler meat were also
observed.
DANMAP 2001
_
_______________
Escherichia coli from food animals
Table 34 presents the MIC distribution and occurrence
of resistance in E. coli from animals at slaughter
(indicator E. coli).
When comparing the results from Table 34 with the
corresponding results from 2000, the resistance levels
among indicator E. coli have remained almost
unchanged. Even though the consumption of tetracycline
in weaner pigs increased markedly between 1999 and
2001, this has resulted in no change in the level of
tetracycline resistance among E. coli from pigs at
slaughter (Figure 16). The E. coli serotypes causing
diarrhoea in weaner pigs are different from the
serotypes that predominate in older pigs. In 2001, only
minor quantities of the total amounts of aminoglycosides
and sulfonamides used in pigs were administrated to
slaughter pigs. In spite of this, streptomycin and
sulfonamide resistance was common among indicator
E. coli from slaughter pigs. Streptomycin and
sulfonamide resistance are often seen in combination
with tetracycline resistance and use of tetracycline may
have co-selected for streptomycin and sulfonamide
resistance.
Table 34. Distribution of MICs and occurrence of resistance among Escherichia coli from
broilers (n=134), cattle (n=85) and pigs (n=304), Denmark
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Ampicillin
Ceftiofur
Sulfonamide
Trimethoprim
Apramycin
Gentamicin
Neomycin
Spectinomycin
Streptomycin
Ciprofloxacin
Nalidixic acid
Colistin
Animal
% Resistant
species [95% Confidence interval]
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
12
5
25
0
0
3
0
0
0
16
0
10
0
0
0
25
4
27
4
0
7
1
0
<1
0
0
0
0
0
4
2
0
31
7
4
40
0
0
0
10
0
2
0
0
0
[7.0-18.7]
[1.3-11.6]
[19.9-29.9]
[0.0-2.7]
[0.0-4.3]
[1.6-6.0]
[0.0-2.7]
[0.0-4.3]
[0.0-1.2]
[10.0-23.0]
[0.0-4.3]
[6.5-13.4]
[0.0-2.7]
[0.0-4.3]
[0.0-1.2]
[17.6-32.8]
[0.7-10.0]
[22.1-32.3]
[1.7-9.5]
[0.0-4.3]
[4.1-10.0]
[0.2-5.3]
[0.0-4.3]
[0.01-1.8]
[0.0-2.7]
[0.0-4.3]
[0.0-1.2]
[0.0-2.7]
[0.0-4.3]
[1.8-6.4]
[0.5-6.4]
[0.0-4.3]
[25.8-36.5]
[3.6-13.3]
[0.7-10.0]
[34.3-45.6]
[0.0-2.7]
[0.0-4.3]
[0.0-1.2]
[5.3-16.0]
[0.0-4.3]
[0.5-3.8]
[0.0-2.7]
[0.0-4.3]
[0.0-1.2]
2.2 3.0
Distribution (%) of MICs
2
4
8
16 32 64 128 256 512 >512
87.3 0.7
2.2
9.7 a)
95.3
1.2 3.5
72.0 3.3
1.3 23.4
2.2 50.7 45.5 1.5
9.4 48.2 41.2 1.2
6.9 53.9 34.9 1.0 2.0 0.3 1.0
6.0 60.4 32.1 1.5
7.1 51.8 41.2
5.9 59.5 33.6 1.0
16.4 46.3 20.9 0.7
1.5 14.2
15.3 58.8 24.7 1.2
15.1 50.0 24.7 0.7
0.3 9.2
97.8 2.2
100
99.0 1.0
74.6 0.7
24.6
92.9 3.5
3.5
71.7 1.3
27.0
94.8 0.7
4.5
100
93.1 0.3
6.6
53.0 45.5 1.5
84.7 15.3
88.2 11.5 0.3
97.0 3.0
100
97.7 2.3
100
98.8 1.2
95.7 0.7
0.3 1.0 2.3
1.5 73.9 19.4 3.0 2.2
1.2 81.2 17.6
0.3 1.3 54.9 8.2 4.3 11.5 19.4
5.2 71.6 15.7 1.5 4.5 1.5
18.8 71.8 5.9 2.4 1.2
21.4 32.2 6.6 10.2 15.8 13.8
6.7 0.7
0.3 1.3
0.3
<=0.03 0.06 0.12 0.25 0.5
87.3
100
98.0
41
1
89.6
97.6
98.4
99.3
100
100
0.7
0.7
3.0
3.7
2.2
0.3
0.3
0.7
0.3
2.4
0.7
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the
highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
42
__
According to VetStat figures from 2001, 86% of the total
fluoroquinolone consumption in pigs was administrated
to piglets and weaner pigs and only 14% to older pigs.
This distribution of usage among age groups may
explain the low level of nalidixic acid resistance among
indicator E. coli from pigs at slaughter. No indicator E.
coli isolates were ciprofloxacin resistant but 14 and 5
isolates from broilers and pigs, respectively had
ciprofloxacin MIC-values between 0.12 and 1.0.
Seventeen of the 19 isolates were resistant to nalidixic
acid. According to NCCLS guidelines these isolates are
susceptible to ciprofloxacin, however clinical
experiences shows that in humans the response of such
isolates to treatment with ciprofloxacin is considerably
reduced.
___
DANMAP 2001
of tetracycline resistance may be a result of co-selection
by other compounds.
Escherichia coli from food
A total of 362 isolates of E. coli were collected from
broiler meat, other poultry meat (predominantly turkey
meat), beef and pork at retail outlets. One hundred and
six of the isolates (29%) originated from imported foods.
Table 35 presents the MIC distribution and occurrence of
resistance. Resistance against ampicillin, tetracycline,
sulfonamide, trimethoprim and streptomycin were the
most frequent. Compared to results from previous years,
the resistance level in E. coli from foods has remained
almost constant.
Escherichia coli from farm to table
In 2001, ampicillin, nalidixic acid, sulfonamide and
tetracycline were the most commonly observed
resistance phenotypes among indicator E. coli from
broilers (Table 34 and Figure 16). This reflects quite well
the consumption of antimicrobials in poultry where
penicillins, sulfonamides, and fluoroquinolones were the
most commonly used antimicrobials (Table 4). There
was little use of tetracycline in broilers and the presence
A comparison of resistance levels in food animals and
food is given in Table 36.
In general, the resistance levels in E. coli from Danish
animals and food of Danish origin were similar, while the
resistance levels found in E. coli from imported broiler
meat products was higher than the levels found in
Danish products.
DANMAP 2001
% resistant isolates
100
Broilers
Cattle
Pigs
80
60
40
20
0
96
97
Ampicillin
98
99
00
01
96
Nalidixic acid
97
98
99
Sulfonamide
00
01
96
97
Tetracycline
98
99
00
01
Streptomycin
Figure 16. Trends in resistance to some selected antimicrobials among Escherichia coli from food
animals, Denmark
DANMAP 2001
_
_______________
43
Table 35. Distribution of MICs and occurrence of resistance among Escherichia coli from beef (n=94), pork
(n=48), broiler meat (n=122), and other poultry meat (n=98), Denmark
DANMAP 2001
Compound
Food type
Tetracycline
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
Beef
Pork
Broiler meat
Other poultry meat
% Resistant
[95% Confidence interval]
Distribution (%) of MICs
<=0.03 0.06 0.12 0.25
Chloramphenicol
Florfenicol
Ampicillin
Ceftiofur
Sulfonamide
Trimethoprim
Apramycin
Gentamicin
Neomycin
Spectinomycin
Streptomycin
Ciprofloxacin
Nalidixic acid
Colistin
6
38
31
63
1
4
2
11
0
0
0
0
12
23
20
43
0
0
0
0
9
25
32
52
5
10
18
42
0
0
0
0
0
0
0
1
2
8
6
3
0
13
2
8
7
38
20
44
0
0
5
3
3
4
16
18
0
0
0
0
[2.4-13.4]
[24.0-52.7]
[23.1-40.2]
[53.0-72.8]
[0.0-5.8]
[0.5-14.3]
[0.2-5.8]
[5.7-19.2]
[0.0-3.5]
[0.0-7.4]
[0.0-3.0]
[0.0-3.7]
[6.0-20.0]
[12.0-37.3]
[13.0-27.8]
[32.9-53.3]
[0.0-3.5]
[0.0-7.4]
[0.0-3.0]
[0.0-3.7]
[3.8-16.1]
[13.6-39.6]
[23.8-41.0]
[41.7-62.2]
[1.8-12.0]
[3.8-22.7]
[11.7-26.0]
[32.0-52.2]
[0.0-3.5]
[0.0-7.4]
[0.0-3.0]
[0.0-3.7]
[0.0-3.5]
[0.0-7.4]
[0.0-3.0]
[0.0-5.6]
[0.3-7.5]
[2.3-20.0]
[2.3-11.5]
[0.6-8.7]
[0.0-3.5]
[4.7-25.3]
[0.5-7.0]
[3.6-15.5]
[3.1-14.7]
[24.0-52.7]
[13.0-27.8]
[33.9-54.3]
[0.0-3.5]
[0.0-7.4]
[0.5-7.0]
[0.6-8.7]
[0.7-9.0]
[0.5-14.3]
[9.6-23.3]
[11.3-27.5]
[0.0-3.5]
[0.0-7.4]
[0.0-3.0]
[0.0-3.7]
0.5
98.9
97.9
97.5
95.9
1
2
91.5
58.3
67.2
36.7
2.1
6.3
4.9
2.0
4.3
4.2
7.4
3.1
7.4 48.9
12.5 37.5
21.3 43.4
13.3 31.6
1.1
2.1
1.6 0.8
4.1
4
1.1
2.1
1.6
8
1.1
2.1
45.7
37.5
56.6
51.0
54.3
60.4
75.4
76.5
30.9
27.1
15.6
12.2
50.0
52.1
35.2
34.7
40.4
35.4
16.4
20.4
1.1
16
1.1
2.5
2.0
1.1
1.6
1.0
1.1
32
64
128 256 512 >512
2.1 3.2 a)
14.6 22.9
6.6 22.1
20.4 40.8
1.1
4.2
0.8
0.8
1.0 10.2
0.8
11.7
22.9
19.7
42.9
89.4
75.0
62.3
48.0
94.7
89.6
81.1 0.8
57.1 1.0
91.5 8.5
100
88.5 11.5
87.8 12.2
100
100
98.4
99.0
0.8
1.0
5.3
10.4
18.0
41.8
1.1
3.1
24.5
14.6
30.3
15.3
2.1
4.2
1.6 5.7
1.0 12.2
5.7
1.0
2.1
1.1
8.5
25.0
1.6 30.3
1.0 51.0
1.6
97.9
91.7
93.4
92.9
95.7
95.8
84.4
80.6
2.1
0.8
1.0
7.4
6.3
6.6
3.1
61.7
43.8
42.6
37.8
81.9 9.6
70.8 4.2
77.9 10.7
67.3 18.4
6.4
4.2 6.3
7.4 3.3
3.1 4.1
1.1
4.2
2.5
3.1
1.1
4.2 6.3 6.3
2.5 1.6 0.8
3.1 3.1 5.1
2.1 5.3
14.6 16.7
5.7 10.7
8.2 31.6
0.8
1.0
2.1 1.1
4.2
5.7 6.6
6.1 10.2
4.2
1.6
1.6
1.1
2.5
2.0
2.5
1.0
96.8
95.8
83.6
80.6
98.9
100
99.2
100
2.5
2.0
0.8
1.0
2.5
1.0
1.1
0.8
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest
concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
44
__
___
Table 36. Occurrence of resistance (%) among
Escherichia coli from Danish animals and food of Danish
and imported origin
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Ampicillin
Ceftiofur
Broilers
Danish
%
Broiler meat
Danish Imported
%
%
Cattle
Danish
%
Beef
Danish Imported
%
%
Pigs
Danish
%
Pork
Danish
%
12
16
69
5
9
0
25
38
0
1
3
0
1
0
3
4
0
16
0
10
0
43
0
0
0
9
0
20
0
10
0
23
0
0
0
0
0
0
0
0
25
4
23
7
54
46
4
0
10
6
4
4
27
7
25
10
Apramycin
1
0
0
0
0
0
<1
0
Gentamicin
Neomycin
0
0
0
2
0
14
0
0
0
1
0
4
0
4
0
8
Spectinomycin
Streptomycin
2
7
2
11
3
40
0
4
0
6
0
12
31
40
13
38
0
1
6
0
0
0
0
0
10
0
134
9
0
87
31
0
35
0
0
85
3
0
69
4
0
25
2
0
304
4
0
48
Sulfonamide
Trimethoprim
Ciprofloxacin
Nalidixic acid
Colistin
Number of isolates
DANMAP 2001
DANMAP 2001
_
_______________
45
Resistance in bacteria from diagnostic submissions
Bacteria from food animals
The DANMAP programme monitors resistance in the
following bacterial species isolated from diagnostic
submissions from food animals: Escherichia coli from
poultry, cattle and pigs, coagulase negative staphylococci
(CNS) and Staphylococcus aureus from cattle, and
Staphylococcus hyicus from pigs.
Escherichia coli
We have included the serotypes O2 and O78 from
poultry, F5 from cattle (young calves) and serotype O149
from weaned pigs.
The MIC distribution and the occurrence of resistance
are presented in Table 37. When comparing the results
for 2001 with those from 2000, the resistance levels
were found to be almost unchanged for most
antimicrobials. In 2001, tetracycline and sulfonamide
resistance was the most common resistance phenotype
among the 17 E. coli isolates from poultry. VetStat usage
monitoring showed limited use of tetracycline for
treatment of poultry in 2001, somewhat less than the use
of sulfonamide. Tetracycline resistance occurred only in
combination with sulfonamide resistance and it is
possible that the use of sulfonamide selected for
tetracycline resistance.
Table 37. Distribution of MICs and occurrence of resistance among Escherichia coli from diagnostic
submissions from broilers (n=17), cattle (n=86) and pigs (n=196), Denmark
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Ampicillin
Ceftiofur
Sulfonamide
Trimethoprim
Apramycin
Gentamicin
Neomycin
Spectinomycin
Streptomycin
Ciprofloxacin
Nalidixic acid
Colistin
Animal
species
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
Broilers
Cattle
Pigs
% Resistant
[95% Confidence interval]
29
69
67
6
8
32
0
0
<1
6
80
30
0
0
0
35
83
77
12
56
37
0
1
10
0
19
9
0
13
35
0
14
60
6
74
72
0
1
1
12
22
14
0
0
<1
[10.3-56.0]
[57.7-78.2]
[60.3-73.9]
[0.2-28.7]
[3.3-16.1]
[25.7-39.2]
[0.0-19,5]
[0.0-4.2]
[0.01-2.8]
[0.2-28.7]
[70.3-88.0]
[23.8-37.1]
[0.0-19,5]
[0.0-4.2]
[0.0-1.9]
[14.2-61.7]
[72.9-89.9]
[70.0-82.3]
[1.5-36.4]
[44.7-66.5]
[30.5-44.4]
[0.0-19,5]
[0.03-6.3]
[6.4-15.3]
[0.0-19,5]
[11.0-28.5]
[5.1-13.5]
[0.0-19,5]
[6.6-21.7]
[28.1-41.8}
[0.0-19,5]
[7.4-23.1]
[52.5-66.6]
[0.2-28.7]
[63.9-83.2]
[65.1-78.1]
[0.0-19,5]
[0.03-6.3]
[0.1-3.6]
[1.5-36.4]
[13.9-32.3]
[9.3-19.4]
[0.0-19,5]
[0.0-4.2]
[0.01-2.8]
Distribution (%) of MICs
2
4
8
16 32
64
29.4 a)
70.6
31.4
3.5 65.1
31.6 1.0
0.5 6.1 60.7
5.9 52.9 35.3
31.4 60.5
8.2 46.4 12.2 1.0 11.2 2.6
5.9 76.5 17.6
54.7 44.2 1.2
14.3 59.7 24.0 1.5 0.5
5.9 41.2 47.1
5.9
9.3 8.1 1.2 1.2
80.2
21.9 41.3 4.6 2.0
1.5 28.6
94.1 5.9
100
99.5 0.5
58.8 5.9
17.4
23.0 0.5
88.2
11.8
44.2
55.8
62.8
37.2
76.5 23.5
66.3 32.6
1.2
86.2 3.6 0.5
100
79.1
2.3
8.1 8.1
2.3
88.8 0.5
2.0 5.1 1.0
2.6
100
82.6 3.5 1.2
3.5
9.3
63.8 1.5
0.5 6.6 27.6
17.6 64.7 17.6
79.1 4.7
2.3
0.5 29.1 4.6
6.1
41.2 52.9
1.2 23.3 1.2 3.5 12.8
12.2 13.3 2.6 11.2 24.0
<=0.03 0.06 0.12 0.25 0.5
82.4
77.9
83.7
1
128 256 512 >512
5.9
8.1
18.4
0.5
9.7
4.7 9.3
14.3 45.4
5.9
58.1
36.7
5.9 11.8
3.6
2.6
17.4
8.7
1.2
2.3
0.5
1.2
1.0
88.2
77.9
81.6
100
100
99.5
3.6
1.0
1.0
5.1
11.8
4.7 17.4
6.1 1.5
0.5
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the
highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
35.3
82.6
76.0
46
__
Among E. coli F5 from cattle we observed a significant
increase in resistance to nalidixic acid from 7% in 2000
to 22% in 2001. From 1996 to 2001, the overall trend in
nalidixic acid resistance has been a steady increase
(Figure 17).
___
DANMAP 2001
Staphylococci
The isolates of CNS and S. aureus originated from
cases of bovine mastitis while S. hyicus originated from
skin infections in pigs. Only isolates collected during the
first 3 quarters of 2001 are included in this report. The
MIC distribution and the occurrence of resistance are
presented in Tables 38-40. In general, CNS and S.
aureus were susceptible to most antimicrobials with little
change between 2000 and 2001. Trends in resistance to
some selected antimicrobials over a 6 year period
(1996-2001) are presented in Figure 18. In general, S.
hyicus from pigs were more often resistant to
antimicrobials in the test panel than were staphylococci
from cattle. Tetracycline resistance in S. hyicus
increased significantly from 21% in 2000 to 47% in 2001
(Figure 18). The tetracycline usage in the pig production
also increased during this time. Another explanation for
the sudden increase in tetracycline resistance in S.
hyicus could be the spread of a particular clone,
although examination of the resistance profiles have not
been able to confirm this.
In 2001, tetracycline was the most widely used
antimicrobial for treatment of infections in pigs. Between
1996 and 2001, 50% to 70% of E. coli O149 isolates
from weaned pigs were resistant to tetracycline - only
sulfonamide resistance occurred more frequently (Figure
17). Nalidixic acid resistance has decreased among E.
coli O149 from 1998 to 2001, reflecting the decreased
use of fluoroquinolones for oral medication in pigs (see
DANMAP 2000 for analysis of usage trend). However,
nalidixic acid resistance remains more frequent among
E. coli O149 from weaner pigs, compared to indicator
E. coli (not serotyped) from pigs at slaughter (Figure 16
and Figure 17). This reflects the consumption pattern in
pigs where 86% of the fluoroquinolones were used in
piglets and weaned pigs while only 14% were
administrated to slaughter pigs.
We observed a decrease in erythromycin resistance in
S. hyicus after use of tylosin as growth promoter in
slaughter pigs was discontinued in March 1998.
However, from 1999 to 2001, no further decrease
occurred in erythromycin resistance (Figure 18). A likely
explanation could be that tylosin remains used for
treatment of disease in pigs with increasing usage
between 1999 and 2001.
Apramycin was first marketed in Denmark in 1998 and
is used for treatment of infections in pigs and calves.
Certain apramycin resistance genotypes are crossresistant to gentamicin. In 2001, we observed for the first
time an increase in resistance to gentamicin among E.
coli from pigs (Figure 17), even though the usage of
gentamicin remained unchanged. It is possible that the
increase is caused by use of apramycin, however, we
have not yet examined the genetic basis for the
emerging gentamicin resistance.
DANMAP 2001
Poultry
% resistant isolates
100
Cattle
Pigs
80
60
40
20
0
96
97
Ampicillin
98
99
00
01
Gentamicin
96
97
98
99
Nalidixic acid
00
01
96
Sulfonamide
97
98
99
00
01
Tetracycline
Figure 17. Trends in resistance to some selected antimicrobials among Escherichia coli from diagnostic
submissions from animals, Denmark
DANMAP 2001
_
_______________
Table 38. Distribution of MICs and occurrence of resistance among coagulase negative
staphylococci from cattle (n=59), Denmark
DANMAP 2001
Compound
% Resistant
[95% Confidence interval]
Distribution (%) of MICs
<=0.06
0.12
0.25 0.5
2
4
8
Tetracycline
0
[0.0-6.1]
Chloramphenicol
0
[0.0-6.1]
3.4
Florfenicol
0
[0.0-6.1]
52.5
45.8
1.7
1.7
3.4
1.7
Oxacillin
0
[0.0-6.1]
Penicillin
25
[15.0-38.4]
Ceftiofur
0
[0.0-6.1]
94.9
1
72.9
1.7
3.4
5.1
98.3
1.7
6.8
5.1
Sulfonamide
5
[1.1-14.2]
14
[6.0-25.0]
Erythromycin
0
[0.0-6.1]
Gentamicin
0
[0.0-6.1]
Kanamycin
0
[0.0-6.1]
Spectinomycin
2
[0.04-9.1]
Streptomycin
5
[1.1-14.2]
Ciprofloxacin
2
[0.04-9.1]
Vancomycin
0
[0.0-6.1]
79.7
Virginiamycin
0
[0.0-6.1]
100
100
Quinupristin/dalfopristin
0
[0.0-6.1]
5
[1.1-14.2]
Bacitracin
24
[13.6-36.6]
32
64
128 256 512 >512
39.0 54.2
3.4
1.7
25.4 30.5 40.7
Trimethoprim
Avilamycin
16
1.7 3.4 a)
8.5 22.0 22.0 16.9 20.3
42.4
47.5 49.2
15.3
10.2 18.6
6.8
1.7
5.1
1.7
3.4
5.1
3.4
100
100
13.6 84.7
61.0
78.0
22.0 11.9
1.7
20.3
1.7
3.4
1.7
18.6
37.3
1.7
44.1 13.6
3.4
1.7
47.5
3.4 25.4 16.9
6.8
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than
the highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest
concentration
Table 39. Distribution of MICs and occurrence of resistance among
Staphylococcus aureus from cattle (n=60), Denmark
Compound
% Resistant
[95% Confidence interval]
Tetracycline
0
[0.0-6.0]
Chloramphenicol
0
[0.0-6.0]
Florfenicol
0
[0.0-6.0]
Oxacillin
0
[0.0-6.0]
Penicillin
18
[9.5-30.4]
Ceftiofur
0
[0.0-6.0]
Sulfonamide
0
[0.0-6.0]
Trimethoprim
0
[0.0-6.0]
Erythromycin
0
[0.0-6.0]
Gentamicin
0
[0.0-6.0]
Kanamycin
0
[0.0-6.0]
Spectinomycin
5
[1.0-13.9]
Streptomycin
0
[0.0-6.0]
<=0.06 0.12 0.25
0.5
Distribution (%) of MICs
1
2
4
8
16
3.3
1.7
1.7
5.0
5.0
73.3
21.7
5.0 55.0
98.3
1.7 93.3
96.7
[0.0-6.0]
100
100
[0.0-6.0]
1.7
5.0 48.3 43.3
0
0
3.3
1.7
100
Virginiamycin
Bacitracin
1.7
40.0
[0.0-6.0]
[0.0-6.0]
8.3
10.0 11.7 50.0 25.0
[0.0-6.0]
[0.04-8.9]
8.3 88.3
46.7 38.3 13.3
0
0
128 256 512
100
81.7
0
2
64
23.3 76.7
Ciprofloxacin
Quinupristin/dalfopristin
32
100 a)
Vancomycin
Avilamycin
DANMAP 2001
51.7 41.7
5.0
3.3
6.7
3.3
21.7 65.0 11.7
1.7
91.7
5.0
3.3
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. MICs equal to or lower than the lowest concentration
tested are given as the lowest concentration
47
48
__
___
DANMAP 2001
Table 40. Distribution of MICs and occurrence of resistance among Staphylococcus
hyicus from pigs (n=53), Denmark
DANMAP 2001
Compound
% Resistens
[95% Confidence interval]
Tetracycline
47
[33.3-61.4]
Chloramphenicol
0
[0.0-6.7]
Florfenicol
0
[0.0-6.7]
Oxacillin
0
[0.0-6.7]
Penicillin
62
[47.9-75.2]
Ceftiofur
0
[0.0-6.7]
Sulfonamide
4
[0.5-13.0]
Trimethoprim
21
[10.8-34.1]
Erythromycin
26
[15.3-40.3]
0
[0.0-6.7]
Gentamicin
Kanamycin
8
[2.1-18.2]
Spectinomycin
21
[10.8-34.1]
Streptomycin
43
[29.8-57.7]
Ciprofloxacin
8
[2.1-18.2]
Vancomycin
0
[0.0-6.7]
Distribution (%) of MICs
<=0.06 0.12 0.25 0.5
1
50.9
2
4
8
16
1.9
32
64
128 256 512
3.8 34.0 9.4 a)
13.2 86.8
58.5 41.5
100
37.7
1.9
3.8 13.2 11.3 11.3 20.8
3.8 62.3 34.0
37.7 43.4
5.7 20.8 35.8 17.0
9.4
5.7
3.8
20.8
7.5 66.0
1.9 24.5
100
86.8
5.7
7.5
5.7 73.6
7.5 32.1 17.0
84.9
7.5
20.8
9.4 11.3 22.6
7.5
96.2 3.8
Virginiamycin
4
[0.5-13.0]
86.8 7.5
1.9
Quinupristin/dalfopristin
4
[0.5-13.0]
96.2
1.9
1.9
3.8
Avilamycin
0
[0.0-6.7]
7.5 83.0
9.4
Bacitracin
0
[0.0-6.7]
15.1 49.1 35.8
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater
than the highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the
lowest concentration
DANMAP 2001
CNS
% resistant isolates
80
S. aureus
S. hyicus
60
40
20
0
96
97
98
99
Erythromycin
00
01
96
Penicillin
97
98
99
Sulfonamide
00
01
96
97
Trimethoprim
98
99
00
01
Tetracycline
Figure 18. Trends in resistance to some selected antimicrobials among staphylococci
from diagnostic submissions from animals, Denmark
DANMAP 2001
_
Bacteria from humans
For Salmonella spp., Campylobacter spp.,
Streptococcus pneumoniae and Staphylococcus
aureus, this report includes data representing the whole
country. For Escherichia coli and coagulase-negative
staphylococci, this report includes data from the clinical
microbiology laboratories serving the Copenhagen and
Frederiksberg municipalities, which have status of
counties, and the counties of Copenhagen, Roskilde,
West Zealand, Storstroem, Ribe, Ringkoebing, Aarhus,
Viborg and North Jutland, which represent more than
70% of the Danish population. Some of these
laboratories did not routinely test for resistance in
Streptococcus pyogenes and the data for this
microorganism cover only 56% of the population. More
information on demographics is presented in Table 2,
page 10.
Escherichia coli
The results for eleven counties for the period 1995-2001
are presented in Figures 19 and 20. As the number of
laboratories that participate in DANMAP increases, it is
becoming more difficult to represent and make sense of
the data that have been collected since the beginning of
the project. However, we still find it too early to pool
these data from various origins since standardisation of
surveillance methods, e.g. algorithm for removal of
duplicate isolates, has not yet been achieved. This
stresses the need for a national working group on
antimicrobial resistance surveillance to clearly define
these methods before a Danish electronic surveillance
system is implemented.
Figure 19 shows the level of resistance to selected
antimicrobials among E. coli blood isolates. As in 2001,
and possibly with the exception of one county, data from
2001 confirm that the general increase in ampicillin
resistance in E. coli blood isolates has stopped and
remains at between 30% and 45%. The sharp variations
observed in some counties between 2000 and 2001 are
likely to be due to the smaller number of isolates tested
in these counties. Similarly to what has been reported
during the past years, gentamicin and cefuroxime
resistance in E. coli blood isolates remained low in
2001. Figure 20 shows the level of resistance to
selected antimicrobials among E. coli urine isolates.
The results are presented separately for isolates from
primary health care and from hospitals. Despite a
resistance level of between 30% and 40%, sulfonamides
still represent the drug of choice for treating urinary tract
infections in Denmark. One should be aware that, in
primary health care, a significant proportion of urine
samples is submitted to the laboratory because of
treatment failure and therefore represents a selected
_______________
49
population. Additionally, one cannot exclude differences
in the frequency of sampling among counties which
precludes any comparison of resistance levels.
However, if each county is considered separately,
sulfonamide resistance was always higher in primary
health care than in hospitals. This observation is
consistent with the fact that sulfonamide use is very low
in Danish hospitals (Table 11, page 24). Ampicillin
resistance in E. coli urine isolates ranged between 35%
and 45%. Finally, ciprofloxacin resistance in E. coli urine
isolates remained very low in 2001.
Coagulase-negative staphylococci
Figure 21 shows the level of resistance to selected
antimicrobials among coagulase-negative staphylococci
blood isolates from eleven counties. As in most other
countries, penicillin resistance was almost 80%.
Methicillin resistance varied amoung counties from less
than 10% to approximately 50%. However, it is possible
that differences in the level of resistance were merely
the consequences of the procedure for selection of
isolates that are submitted for susceptibility testing. For
example, the laboratories reporting the highest percentage of methicillin-resistant coagulase-negative
staphylococci mentioned that they only perform
susceptibility testing in isolates of clinical significance.
Caution is therefore warranted when trying to make
comparisons of resistance levels among counties.
Finally, erythromycin resistance in coagulase-negative
staphylococci blood isolates ranged betweem 20% and
40% depending on the county.
Streptococcus pneumoniae
As the national reference centre, the Streptococcus Unit
at the Statens Serum Institut performs typing and
susceptibility testing on S. pneumoniae isolates
referred by the Danish local clinical microbiology
laboratories. In 2001, susceptibility testing was performed on 981 non duplicate isolates from blood or spinal
fluid samples. Resistance to penicillin in S. pneumoniae
isolates is an increasing problem worldwide. In Denmark, this type of resistance was rare until 1995 when it
started to increase reaching a peak at approximately
4% in 1999. In 2000, there was a slight decrease in the
percentage of penicillin-non susceptible S. pneumoniae
and this decrease continued reaching 2% in 2001
(Figure 22).
Resistance to erythromycin has been increasing since
1992 and reached 5% among isolates from blood and
spinal fluid in 2000. In 2001, the level of resistance
remained at 5% (Figure 22). This was surprising since
there has been no major change in overall macrolide
consumption, which has remained at about 2 DDD/
50
__
___
DANMAP 2001
DANMAP 2001
50
Ampicillin
Gentamicin
DANMAP 2001
50
Cefuroxime
Gentamicin
Cefuroxime
% resistant isolates
40
30
20
30
20
10
0
0
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
10
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
% resistant isolates
40
Ampicillin
Copenhagen+Frederiksberg Municipalities - hospitals
(n=478)
Copenhagen County - hospitals (n=434)
Ribe County - hospitals (n=119)
Ringkoebing County - hospitals (n=107)
Aarhus County - hospitals (n=560)
Viborg County - hospitals (n=148)
North Jutland County - hospitals (n=379)
Roskilde County - hospitals (n=230)
Figure 19. Resistance (%) to selected antimicrobials in Escherichia coli blood isolates from humans,
Denmark. The number n in parentheses represents the number of isolates tested for antimicrobial
susceptibility in 2001
DANMAP 2001
50
Sulfonamide
Ampicillin
DANMAP 2001
50
Ciprofloxacin
Ampicillin
Text
box 1
Ciprofloxacin
40
% resistant isolates
% resistant isolates
40
Sulfonamide
30
20
30
20
10
10
Copenhagen+Frederiksberg Municipalities - hospitals (n=6,319)
Copenhagen+Frederiksberg Municipalities - primary health care (n=4,440)
Copenhagen County - hospitals (n=6,631)
Copenhagen County - primary health care (n=1,680)
Roskilde County - hospitals (n=2,142)
Roskilde County - primary health care (not reported)
West Zealand County - hospitals (n=2,089)
West Zealand County - primary health care (n=888)
Storstroem County - hospitals (n=1,855)
Storstroem County - primary health care (n=744)
0
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
20
01
19
99
19
97
19
95
20
01
19
99
19
97
19
95
20
01
19
99
19
97
19
95
0
Ribe County - hospitals (n=1,063)
Ribe County - primary health care (n=360)
Ringkoebing County - hospitals (n=761)
Ringkoebing County - primary health care (n=879)
Aarhus County - hospitals (n=4,241)
Aarhus County - primary health care (n=3,007)
Viborg County - hospitals (n=1,595)
Viborg County - primary health care (n=669)
North Jutland County - hospitals (n=3,337)
North Jutland County - primary health care (n=2,652)
Figure 20. Resistance (%) to selected antimicrobials in Escherichia coli urine isolates from humans,
Denmark. The number n in parentheses represents the number of isolates tested for antimicrobial
susceptibility in 2001.
DANMAP 2001
_
_______________
DANMAP 2001
100
Penicillin
Methicillin/Oxacillin
100
Erythromycin
DANMAP 2001
Penicillin
Methicillin/Oxacillin
Erythromycin
80
% resistant isolates
80
60
40
60
40
20
0
0
Copenhagen+Frederiksberg Municipalities - hospitals (n=771)
Copenhagen County - hospitals (n=613)
Roskilde County - hospitals (n=221)
West Zealand County - hospitals (n=177)
Storstroem County - hospitals (n=181)
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
20
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
19
95
19
97
19
99
20
01
% resistant isolates
51
Ribe County - hospitals (n=51)
Ringkoebing County - hospitals (n=104)
Aarhus County - hospitals (n=863)
Viborg County - hospitals (n=213)
North Jutland County - hospitals (n=101)
Figure 21. Resistance (%) to selected antimicrobials in coagulase-negative staphylococci blood isolates
from humans, Denmark. The number n in parentheses represents the number of isolates tested for
antimicrobial susceptibility in 2001
1,000 inhabitant-days during the past years (Table 10,
page 20). In Denmark, the prevalence of erythromycinresistant S. pneumoniae started to increase following
the introduction of azithromycin and then showed a
parallel increase to consumption of this macrolide, while
during the same period consumption of other macrolides
either decreased or remained the same (Figure 2, page
20). Since 1999, there has been no further increase in
azithromycin consumption, which could well be the cause
for the interruption observed in the increase in
erythromycin-resistant S. pneumoniae.
Preliminary results from a multivariate model that tested
consumption of each individual antimicrobial during
1995-1999 showed that azithromycin consumption was
the most powerful independent factor associated with
erythromycin resistance in S. pneumoniae at the county
level. Other preliminary data from typing showed that
most erythromycin-resistant S. pneumoniae isolated in
Denmark during this period corresponded to a single
clone (Margit Kaltoft, personal communication). These
results suggest that the increase in erythromycinresistant S. pneumoniae in Denmark was due to both
person-to-person transmission of a successful clone and
pressure due to consumption of macrolides in primary
health care. The possible differential effect of
antimicrobial pressure due to macrolides with different
half-lives is currently under investigation.
Streptococcus pyogenes
In 2001 we introduced surveillance of macrolide
resistance in S. pyogenes (group A streptococci or
GAS). Until now, resistance to macrolides has been
considered a minor problem in Denmark, but increasing
resistance worldwide has called for closer monitoring.
Among a total of 4,875 GAS isolates from various
clinical samples in nine counties, resistance to
erythromycin was 2.7% [95% C.I.: 2.3-3.2], with countyto-county variations ranging from 0.4% to 4.5%. As for S.
pneumoniae, both the maintained high level of overall
consumption of macrolides and changes in the distribution of the macrolides used could result in an increase in
erythromycin-resistant GAS in Denmark as seen in other
countries. To monitor a possible increase in
erythromycin resistance, DANMAP will now include GAS
in its surveillance. Additionally, preliminary reports on the
distribution of macrolide resistance genes among GAS
isolates found all three genes to be present in Denmark
with ermB being the most frequent. Typing found 14
different patterns among erythromycin-resistant GAS,
thus showing that macrolide resistance in GAS is not a
clonal problem as seen for S. pneumoniae. Forty-eight
percent of the erythromycin-resistant GAS isolates were
also resistant to tetracycline.
52
__
Staphylococcus aureus
For the past 20 years, methicillin-resistant S. aureus
(MRSA) represented less than 1% of S. aureus blood
isolates and more than one half of these MRSA strains
had been acquired outside Denmark. Last year, we
reported on a slow increase in the overall number of
MRSA cases in Denmark. During the past year, we
performed a detailed analysis of the MRSA register
maintained by the Staphylococcus Unit at the Statens
Serum Institut for the period 1999-2001. It was then
completed by an analysis of patients’ discharge letters
and of a database containing the pulsed-field gel
electrophoresis (PFGE) profiles of all strains.
Although part of the increase was due to an increasing
number in MRSA isolates from active screening
samples, there has been an increase in reported MRSA
infections from 54 cases in 1999 to 83 in 2001 (Figure
23). The number of MRSA infections imported from other
countries showed little variations during 1999-2001. The
___
DANMAP 2001
analysis confirmed that most of the increase observed in
2000 was due to three outbreaks in Danish hospitals
involving three different MRSA clones. These outbreaks
were quickly controlled. Additionally, there has been a
steady increase in reported MRSA infections in primary
health care during 1999-2001. About 60% of these
community MRSA infections were due to a single clone
named EDK97-1 (Figure 23). This clone first started
spreading in 1997 in the county of North Jutland and has
since been spreading in the rest of the Danish
community. In 2001, infections due to this clone were
reported from 11 of the 16 Danish counties. Clone
EDK97-1 is still very rarely isolated from hospitalised
patients with only 1 infection reported in 2000 and 2
infections in 2001. Despite the very low prevalence of
MRSA in Denmark, this new trend in the community is
worrying. It stresses the importance of maintaining a
Danish MRSA register that includes information on
patient, location, type of infection and PFGE typing.
DANMAP 2001
6%
Penicillin (MIC >= 0.125 ug/ml)
5%
Erythromycin (MIC >= 1 ug/ml)
4%
3%
2%
1%
0%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Figure 22. Resistance (%) to selected antimicrobials in Streptococcus pneumoniae blood and spinal fluid
isolates from humans, Denmark
No. new reported MRSA cases
DANMAP 2001
120
Active screening
(colonisation)
100
Infection, Imported
80
Infection, Danish hospitals
60
Infection, Danish primary
health care (other clones)
40
20
Infection, Danish primary
health care (clone EDK97-1)
0
1999
2000
2001
Figure 23. New reported cases of human infection or colonisation by methicillin-resistant Staphylococcus
aureus (MRSA), Denmark
DANMAP 2001
_
_______________
53
Text box 4
Epidemiology and antifungal susceptibility of human Candida
bloodstream isolates in Denmark
Invasive Candida infections are increasing in many
countries as a consequence of an increasing
number of patients at risk for these infections. Risk
factors for infection include indwelling devices,
treatment with broad-spectrum antimicrobials and/or
immunosuppressive agents and complicated
abdominal surgery. In Denmark, information on the
epidemiology and antifungal susceptibility of these
infections is sparse due to the lack of a surveillance
program and to the fact that only a small proportion
of Candida isolates are tested for susceptibility to
antifungals. Indeed, while antimicrobial susceptibility
testing of bacteria has been performed on a routine
basis for decades, a standardized method for
antifungal susceptibility testing of yeasts has only
been available for 4 years. Susceptibility patterns
vary among Candida species. Candida albicans is
generally susceptible to fluconazole, whereas C.
glabrata is intrinsically less susceptible and C.
krusei resistant to this widely used antifungal.
Therefore, changes in species distribution are also
used as an indirect indicator for changes in
susceptibility patterns.
An increase in the number of candidemia cases,
and in particular in the number of non-albicans
Candida species, has been observed in Denmark
during the last decade. Schønheyder et al. [1]
reported an increase in candidemia in the county of
North Jutland over a 6-year period, highest among
intensive care unit patients in whom incidence rose
from 4 to 30 per 1,000 blood culture episodes
between 1995-1996 and 1999-2000. Candida
albicans accounted for 77% of these episodes. A
similar increase in the number of candidemia episodes
has been observed in Copenhagen County, with a
simultaneous increase in episodes due to isolates not
fully susceptible to fluconazole (Figure). Candida
albicans accounted for 85% of the episodes in 19941996 and for 81% in 1998-2001 [2, 3]. Finally, 55 cases
of candidemia, of which only 47% involved C. albicans,
were diagnosed during 1987-1997 among patients with
underlying haematological diseases admitted at Rigshospitalet, a Copenhagen university hospital that includes
a bone marrow transplant unit [4].
In conclusion, there are very few studies on the
epidemiology and susceptibility of candidemia in Denmark. However, available data indicates an increasing
incidence of candidemia in general and an increase of
Candida blood isolates with reduced susceptibility to
fluconazole in particular.
References:
1.
Schønheyder HC. Candidæmi i Nordjyllands amt
– en opfølgning. Nyt om Mikrobiologi 2001;(57): 5.
2.
Arendrup M, Lundgren B, Jensen IM, Hansen BS,
Frimodt-Møller N. Comparison of Etest and a
tablet diffusion test with the NCCLS broth
microdilution method for fluconazole and
amphotericin B susceptibility testing of Candida
isolates. J Antimicrob Chemother 2001, 47:521-6.
3.
Jarløv JO. Dept. of Clinical Microbiology, Herlev
Hospital, Denmark. Personal communication.
4.
Bruun B, Christensen BE, Ellegård J, et al.
Svampeinfektioner. In: Infektioner hos
hæmatologiske og onkologiske patienter.
Odense Universitets Forlag 2000: 25-31.
Candidemia in the County of Copenhagen
Candida
Number of episodes
30
Candida albicans
Fluconazolenon susceptible
C. albicans
20
non-albicans
Candida species
10
0
1994
1995
1996
1997
1998
1999
2000
2001
Fluconazolenon susceptible
non-albicans
Candida species
For further details, please contact: Maiken Arendrup, MD, PhD, Statens
Serum Institut, Unit of Mycology, Artillerivej 5, DK-2300 Copenhagen S, Denmark. E-mail: [email protected]
54
DANMAP 2001 - Appendix 1
Appendix 1
Materials and methods
Data on consumption of antimicrobials
therapy. From 2001, information on usage of
coccidiostats was collected using the VetStat system.
Antimicrobials in animals
In Denmark, all antimicrobials used in therapy are
prescription-only medicines and must be distributed
through pharmacies. The pharmacy either sells the
medicines to veterinarians for use in practice or for resale to farmers, or will sell directly to the animal owner on
presentation of a prescription. By law, the profit that
veterinarians can make on the sale of medicines is
severely limited and thus they have little financial
enticement to sell medicines. Accordingly, an estimated
80% of all antimicrobials used for therapy in food
animals are sold to farmers by pharmacies on the basis
of a veterinary prescription.
In previous DANMAP reports data on antimicrobial
usage in animals has been based on sales figures
reported by the pharmaceutical industries. In 2000, the
VetStat programme was initiated. This programme
collects data on antimicrobial usage close to the point of
use and is prescription based.
Reports from pharmaceutical companies. All
medicines must be given a marketing authorisation by
the Danish Medicines Agency (DMA), and importers and
manufacturers are required to provide an annual report
to the DMA on the quantities sold. These statistics will
be affected by changes in the stocks held by
wholesalers and pharmacies and provide little information on the food animal species in which the
antimicrobials are used. Products and formulations
obviously intended for use only in pets have been
excluded from the statistics shown in this report.
The results shown in Table 3, page 11 were rounded, so
that quantities between 1 and 25 are shown as
”< 25”; quantities between 25 and 1,000 were rounded
to the nearest 50, and quantities over 1,000 kg were
rounded to the nearest 100.
The Danish Plant Directorate is responsible for the
collection of data on the use of antimicrobials for growth
promotion and on the use of coccidiostats. The statistic
is based on compulsory reporting by companies
authorised to produce premixes containing
antimicrobials. The system used for collection of data
allows us to discriminate between the quantities of, for
example tylosin, used for growth promotion and for
The VetStat programme – Point of use data. For
details about data collection in the VetStat system,
please refer to the Text box 1 on page 12-13.
Antimicrobial groups used when reporting sales on
basis of information from pharmaceutical companies
and the VetStat prescription database are presented in
the Text boxes 5 and 6, respectively.
Antimicrobials in humans
The Danish Medicines Agency (DMA) has the legal
responsibility for monitoring the consumption of all
medicinal products in humans. This is done by monthly
reporting from all pharmacies in Denmark, including
hospital pharmacies, to the DMA. Data from the primary
health care sector have been collected since 1994,
whereas valid data on consumption in hospitals are only
available from 1997.
In Denmark, all antimicrobials for use in humans are
prescription-only medicines. All antimicrobials are sold
by pharmacies in defined packages. Each package is
uniquely identified by a code, which can be related to the
size of the package (by content and in Defined Daily
Doses or DDD), to the code of the antimicrobial in the
Anatomical Therapeutic Chemical (ATC) classification
system, and to the name of the producer. In addition, the
following information is collected for each transaction:
social security number (CPR-number) of the patient,
code identifying the prescribing physician, date and
place (pharmacy, hospital pharmacy, institution) of the
transaction, and information regarding reimbursement of
cost if applicable. Information on the indication for the
prescription is not yet available. The data are transferred
monthly to the DMA in an electronic format. On-line
transfer of the transactions in real time is being
established.
The present report includes data on the consumption of
antibacterials for systemic use, or group J01 of the 2001
update of ATC classification system, in primary health
care and in hospitals. As recommended by the World
Health Organization (WHO), consumption of
antimicrobials in primary health care is expressed as a
number of DDD per 1,000 inhabitants and per day
(DDD/1,000 inhabitant-days) and consumption of
antimicrobials in hospitals is expressed as a number of
DANMAP 2001 - Appendix 1
55
Text box 5
DANMAP- Antimicrobial groups
Categorisation of antimicrobials used when reporting sales on the basis of information from
pharmaceutical companies
DANMAP antimicrobial category
Aminoglycosides
Cephalosporins
Macrolides + lincosamides
Penicillins with narrow spectrum
Penicillins with extended spectrum
Fluoroquinolones
Sulfonamides
Sulfonamides + trimethoprim
Tetracyclines
Others
Active antimicrobial included in category
Apramycin, dihydrostreptomycin, framycetin, gentamicin, neomycin, spectinomycin
Cefadroxil, cefalexin, cefapirin, cefoperazone, cefquinom, ceftiofur,
Lincomycin, spiramycin, tiamulin, tilmicosin, tylosin,
Benzylpenicillins, benethamin penicillin, benzathine penicillin, penethamath hydroiodide
Amoxycillin, ampicillin, cloxacillin, nafcillin
Danofloxacin, difloxacin, enrofloxacin, marbofloxacin
Sulfadimidine
Baquiloprim, sulfadiazine, sulfadimidine, sulfadoxine, sulfatroxazole, trimethoprim
Chlortetracycline, doxycycline, oxytetracycline, tetracycline
Bacitracin, colistin, florphenicol
Text box 6
VetStat - Antimicrobial groups
Categorisation of antimicrobials used when reporting usage on the basis of the VetStat prescription
database
Antimicrobial category
VetStat antimicrobial
category abbreviation
Amphenicols
Aminoglycosides
Amcol
Amglc
Cephalosporins
Fluoroquinolones
Quinolones
Lincosamide
Macrolides
Ceph
FQ
Quinol
Linco
Macrol
Penicillins with narrow
spectrum
Penicillins with extended
spectrum
Sulfonamides and
sulfonamides with
trimethoprim
Tetracyclines
Others
Pen-sim
Pen-ext
Antimicrobial agents included in category
Chloramphenicol, florphenicol
Apramycin, dihydrostreptomycin, framycetin, gentamicin, neomycin,
spectinomycin
Cefadroxil, cefalexin, cefapirin, cefoperazone, cefquinom, ceftiofur
Danofloxacin, difloxacin, enrofloxacin, marbofloxacin
Oxolinic acid
Lincomycin
Azithromycin, clindamycin, erythromycin, spiramycin, tiamulin, tilmicosin,
tylosin
Benzyl penicillin, benzyl penicillin procaine, penethamat hydroiodide, pencillin
benethamine, phenoxymethyl penicillin
Amoxicillin, ampicillin, cloxacillin benzathine, nafcillin
Sulfa-TMP
Baquiloprim, sulfaclozine, sulfadiazine, sulfadimidine, sulfadoxine,
sulfamethizole, sulfamethoxazole, sulfathiazole, sulfatroxazole, trimethoprim
Tet
Others
Chlortetracycline, doxycycline, oxytetracycline, tetracycline
Bacitracin, colistin, fusidic acid, metronidazole, polymyxins
56
DDD per 1,000 beds and per day (DDD/1,000 beddays). Data on the number of bed-days in each hospital
were obtained from the National Board of Health (http://
www.sst.dk).
Collection of bacterial isolates
Isolates from animals
Bacterial isolates included in the monitoring programme are collected from animals at slaughter (E.
coli, enterococci and Campylobacter), as well as from
diagnostic submissions (Staphylococcus hyicus from
pigs and coagulase negative staphylococci and
Staphylococcus aureus from examination of cattle for
mastitis, and E. coli from diarrhoea in cattle and pigs
and septicaemia in poultry). Finally, Salmonella
isolates from subclinical infections as well as from
cases of clinical salmonellosis are included.
The samples from animals at slaughter are collected by
meat inspection staff or company personnel and sent to
the Danish Veterinary Institute for examination. The
number of samples for each plant has been determined
in proportion to the number of animals slaughtered per
year. Each sample represents one herd or flock. They
are collected once a month (weekly for broilers). The
broiler, cattle and pig slaughter plants included in the
surveillance programme account for 98%, 80% and
95%, respectively, of the total production of these animal
species in Denmark. Accordingly, the bacterial isolates
may be regarded as representing a stratified random
sample of the respective populations, so that the
occurrence of resistance provides an estimate of the
true occurrence in the populations.
The Salmonella isolates included in DANMAP are
selected as a true random sample among isolates
serotyped at the Danish Veterinary Institute. The DVI is
the national reference laboratory with respect to Salmonella in animals, feeding stuffs and food, and receives
all such isolates for typing.
Bacterial isolates from diagnostic submissions are
selected by a pseudo-random process among isolates
from submissions to the DVI, the Cattle Health
Laboratory in Ladelund and the laboratory of the Federation of Danish Pig Producers and Slaughterhouses in
Kjellerup. Accordingly, the programme achieves nationwide coverage for these pathogens.
DANMAP 2001 - Appendix 1
Isolates from food
All food samples were collected at wholesale and retail
outlets by the Regional Veterinary and Food Control
Authorities (RFCA) during the course of routine
inspection carried out by the authorities, or on request
specifically for the DANMAP surveillance programme.
The collection of food samples for analyses of indicator
bacteria (enterococci and E. coli) was planned and
coordinated by the Danish Veterinary and Food Administration (DVFA). The collected material consisted of
both Danish and imported foods. The food samples
were collected according to the guidelines for
microbiological examination of foods from the DVFA
(Vejledning om mikrobiologisk kontrol af fødevarer,
ISBN: 87-90978-46-3).
Isolates from humans
With the exception of Salmonella Typhimurium isolates
which are all tested for susceptibility to antimicrobials,
Salmonella spp. and Campylobacter spp. from humans
represent a random sample of isolates grown from
faeces samples submitted for microbiological
diagnostic to the Department of Gastrointestinal
Infections at the Statens Serum Institut in 2001.
All Staphylococcus aureus blood isolates nationwide
are sent to the Staphylococcus reference laboratory at
the Statens Serum Institut for confirmation of
susceptibility results, phage typing and pulsed-field gel
electrophoresis (PFGE) typing.
Similarly, all Streptococcus pneumoniae blood and
spinal fluid isolates nationwide are sent to the
Streptococcus Unit at the Statens Serum Institut for
confirmation of susceptibility testing and typing.
Escherichia coli and coagulase-negative staphylococci
from humans represent all isolates recorded from either
blood or urine samples submitted for microbiological
diagnostic at one of the ten participating laboratories
serving the Copenhagen and Frederiksberg
municipalities, Copenhagen county, Roskilde county,
West Zealand county, Storstroem county, Ribe county,
Ringkoebing county, Aarhus county, Viborg county and
North Jutland county, respectively.
Isolation of bacteria
Examination of samples from animals
Salmonella. Examination of samples from cattle and
pigs was done by non-selective pre-enrichment of 22 g
DANMAP 2001 - Appendix 1
material in 200 ml of BPW and incubated overnight at
37oC. A plate with Modified Semi-solid RappaportVassiliadis medium was inoculated with 100 ml of preenrichment broth deposited on the agar as 3 drops.
Overnight incubation at 41.5 oC was followed by
serotyping of suspect colonies by slide agglutination.
Samples from poultry were examined by non-selective
pre-enrichment in BPW of paired sock samples, or
homogenized organs, at a ratio of 1:9 and incubated at
37oC overnight, followed by selective enrichment by
inoculation of 9.9 ml Rappaport-Vassiliadis broth with
0.1 ml pre-enrichment broth and incubation at 41.5 oC
overnight. The selective broth was inoculated onto
Rambach agar. Presumptive Salmonella isolates were
verified and typed by slide agglutination.
Campylobacter. The samples were examined by direct
inoculation of selective agar as well as by selective
enrichment. As selective agar we used CCD agar, which
was incubated in microaerophilic atmosphere with 3%
hydrogen for 1-3 days at 42oC. Selective enrichment
was done by inoculation of Preston broth at a ratio of
1:10, followed by incubation in microaerophilic
atmosphere for 24 h at 42oC. Ten ml of this enrichment
culture was inoculated onto CCD agar and incubated as
described above. Campylobacter-like colonies were
identified by their catalase activity, by their ability to
hydrolyse hippurate and indoxyl acetate, and by their
susceptibility to cephalothine.
Escherichia coli. The material was inoculated directly
onto Drigalski agar and incubated at 37oC overnight.
Yellow colonies that were catalase positive and oxidase
negative were identified according to the following
standard criteria: indole, citrate, methyl red and VogesProskauer reaction.
Enterococci. Enterococci from pigs and cattle were
isolated and identified by the following procedure. One
drop of faecal material suspended in 2 ml sodium
chloride (0.9%) was spread on Slanetz agar and
incubated for 2 days at 42oC. Up to three colonies
showing a morphology typical of E. faecalis and E.
faecium were re-inoculated on Slanetz agar and
incubated for 2 days at 37oC. The isolates were then
sub-cultivated onto aesculine agar. Aesculine positive,
white colonies were identified according to the following
criteria: motility, arginine dihydrolase and the ability to
ferment mannitol, ribose, sorbitol, arabinose, raffinose
and melibiose.
57
Enterococci from broilers were isolated and identified
as follows. Cloacal swabs were incubated overnight at
42°C in Enterococcus Selective Broth, prepared with a
composition identical to that of Enterococcosel broth
(Becton Dickinson). Cultures were streaked on Slanetz
agar and incubated for 48 h at 37°C. Colonies that
morphologically resembled E. faecium and E. faecalis
were identified to species level by using standard
biochemical and physiological tests as described
above. A subset of all isolates verified as E. faecium
and E. faecalis were subjected to antimicrobial
susceptibility testing.
Pathogens. The diagnostic submissions were
examined according to the standard procedures
employed by the participating laboratories. All bacterial
isolates from food animals have been stored at –80oC
for further study as required.
Examination of food samples
The isolation of indicator organisms from food samples
was performed by the RFCA. Subsequently, the isolates
were sub-cultured to standard transport media and
shipped to the Danish Veterinary and Food Administration. Verifications of species identity and MICdeterminations were performed by the DVFA. Only one
strain of E. coli and/or Enterococcus from each food
sample was tested for antimicrobial susceptibility.
The isolation method for E. coli employed 5 grams of
food, which was incubated at 44°C for 18-24 hours in 45
ml of MacConkey- or laurylsulfate-broth. The broth culture
was streak-inoculated onto violet red bile agar and
incubated for 48 hours at 44°C. Presumptive E. coli
were sub-cultured onto blood agar, transferred to
standard transport medium and shipped to DVFA. The
isolates were identified as E. coli by standard
morphological examinations and biochemical tests,
including an api 20E test (bioMérieux, France) or AP80
test (Sensititre).
Analysis for enterococci was carried out by adding 5 g
of the sample to 45 ml of azide dextrose broth, which
was incubated at 44°C for 18-24 hours, and
subsequently streaked onto Slanetz-Bartley agar. After
incubation at 44°C for 48 hours the plates were
examined for growth, and typical red colonies were subcultured on blood agar, then transferred to transport
medium and shipped to the DVFA. The isolates were
identified by standard morphological examinations and
biochemical tests, including an api 20STREP test
(bioMérieux, France) or AP90 test (Sensititre). Only E.
faecium and E. faecalis were included in the
surveillance.
58
DANMAP 2001 - Appendix 1
A few of the Enterococcus and E. coli strains were
isolated in accordance with the Nordic Committee on
Food Analysis (NMKL) No. 68, 2 nd ed., 1992
(Enterococcus) and NMKL No. 125, 3 rd ed., 1996 (E.
coli).
Salmonella isolates were isolated according to NMKL
No. 71, 5 th ed., 1999. Sero- and phage-typing was
performed at DVI.
Thermotolerant Campylobacter spp. was isolated by a
semi-quantitative method. Twenty-five g food sample
was mixed 1:4 with Mueller-Hinton bouillon
supplemented with sodium pyrovate 0.25 mg/l, sodium
metabisulphite 0.25 mg/l, ferro sulphate 0.25 mg/l,
cefaperazone 30 mg/l, and trimethoprim lactate 50 mg/l
and the sample was stomachated. Dilutions 1:10 were
prepared. One ml from each dilution was enriched under
microaerophilic conditions for 24 hours at 42 ºC in 9 ml
of Mueller-Hinton bouillon with supplement (as described
above). After pre-enrichment 10 µl was striked on
mCCDA and further incubated under microaerophilic
conditions for 24-48 hours at 42 ºC. mCCDA plates
were examined for the presence of Campylobacter-like
colonies. Suspected colonies were verified by phasecontrast microscopy, positive oxidase reaction, and
hydrolysis of hippurate- and indoxyl acetate. Species
identification was performed according to NMKL No.
119, 2 nd ed., 1990. Only isolates of C. jejuni were
included in the surveillance.
Examination of samples from humans
Salmonella spp. were isolated from faeces samples
using the SSI Enteric Medium (SSI rød plade, SSI
Diagnostika, Copenhagen, Denmark) and enrichment
using a 0.6% selenite medium (SSI Diagnostika).
Campylobacter spp. were isolated from faeces samples
using a modified CCDA medium (SSI Diagnostika).
Other clinical isolates were isolated on various common
media used in clinical microbiology laboratories.
Susceptibility testing
Isolates from animals and foods
Plate dilution was used to test the susceptibility of
Campylobacter isolates to all animicrobials included in
the panel.
All other susceptibility testing was done with Sensititre
(Trek Diagnostic Systems Ltd.), a commercially
available MIC technique using dehydrated antimicrobials
Table A1. Breakpoints and range of dilutions used for testing bacteria from animals and food. Isolates with
MIC higher than or equal to the figures shown were considered resistant
DANMAP 2001
Antimicrobial agent
Ampicillin
Apramycin
Avilamycin
Bacitracin
Ceftiofur
Chloramphenicol
Ciprofloxacin
Colistin
Erythromycin
Flavomycin
Florfenicol
Gentamicin
Kanamycin
Nalidixic acid
Neomycin
Nitrofurantoin
Oxacillin + 2% NaCl
Penicillin
Salinomycin
Spectinomycin
Streptomycin
Sulfamethoxazole
Quinupristin/dalfopristin a)
E. coli, Salmonella
Breakpoints
µg/ml
32
16
Tetracycline
Trimethoprim
Vancomycin
Virginiamycin
a) The trade name is Synercid
8
32
4
16
Range
Staphylococci
Breakpoints
µg/ml
Range
Enterococci
Breakpoints
µg/ml
Campylobacter
Range
1-32
4-64
0.5-8
2-64
0.03-4
4-64
32
16
2-64
1-32
32
16
4-128
2-32
128
32
512
2-128
4-64
32-512
16
16
2-32
4-32
16
128
8
32
4
2-32
16-256
0.12-16
2-64
0.12-8
16
128
1-32
8-256
32
2-64
8
0.12-16
32
16
64
1-64
1-32
4-128
8
16
32
1,024
2,048
1-32
0.5-32
2-32
128-2,048
128-2,048
4
0.25
0.5-8
0.06-16
128
32
512
4
16
16
32
8
8-256
2-128
8-512
1-32
0.5-32
1-32
1-32
1-32
128
64 - 256
16
16
2-128
1-32
2,048
128-2,048
4
16
0.5-32
32
8
1-32
0.5-32
1-32
Breakpoints
µg/ml
Range
32
1-32
32
4
64
32
1-64
0.03-16
0.5-64
0.25-32
16
0.5-32
64
16
1-128
1-64
16
512
1-64
8-512
16
0.5-32
DANMAP 2001 - Appendix 1
in microtitre wells. The wells were inoculated according
to NCCLS guidelines and incubated aerobically at 37oC
for 18-22 hours. The MIC was defined as the lowest
concentration of antimicrobial with no visible growth. The
breakpoints used are shown in Table A1.
The following strains were used for quality control:
Staphylococcus aureus ATCC 29213, Escherichia coli
ATCC 25922, Pseudomonas aeruginosa ATCC 27853
and Enterococcus faecalis ATCC 29212. In Sensititre,
weekly quality control was performed by inoculation and
incubation of a set of wells with the control stains. The
MIC values for the strains were evaluated in accordance
to NCCLS guidelines and tests re-done if the values
were out of range. With plate dilution, all 4 control strains
were included on each plate.
59
Agar (Resistensplade, SSI Diagnostika) and the
breakpoints defined for this medium by A/S Rosco.
Methicillin resistance was confirmed with a 3-h
hybridization assay for the detection of the mecA gene
(Skov RL, et al. J. Antimicrob. Chemother. 1999; 43:
467-475).
Streptococcus pneumoniae. The Streptococcus Unit
at the Statens Serum Institut screens for penicillinresistant S. pneumoniae using a 1 microgram oxacillin
tablet (Neo-SensitabsÒ, A/S Rosco) on 10% horse
blood agar (SSI Diagnostika). Penicillin MICs are
determined using the E-test (AB Biodisk, Solna,
Sweden) on Danish Blood Agar (Resistensplade, SSI
Diagnostika). The breakpoints used are those defined
by the National Committee for Clinical Laboratory
Standards (NCCLS).
Isolates from humans
Gastrointestinal pathogens. Susceptibility testing for
Salmonella spp. isolates was performed using the
tablet diffusion method (Neo-SensitabsÒ, A/S Rosco,
Roskilde, Denmark) on Danish Blood Agar (Resistensplade, SSI Diagnostika) and the breakpoints defined in
Table A2.
Susceptibility testing for Campylobacter spp. isolates
was performed using the tablet diffusion method (NeoSensitabsÒ, A/S Rosco) on 5% blood yeast extractsupplemented agar (SSI Diagnostika) and the
breakpoints defined in Table A2.
Staphylococcus aureus. The Staphylococcus Unit at
the Statens Serum Institut is using the tablet diffusion
method (Neo-SensitabsÒ, A/S Rosco) on Danish Blood
Table A2. Breakpoints used for gastrointestinal
pathogens from humans. Isolates were considered
resistant if they had an inhibition zone less than
shown in the table
DANMAP 2001
Antimicrobial agent
Ampicillin
Apramycin
Ceftiofur
Chloramphenicol
Colistin
Ciprofloxacin
Erythromycin
Gentamicin
Kanamycin
Nalidixic acid
Spectinomycin
Streptomycin
Sulfonamide
Tetracyclin
Trimethoprim
Species
Salmonella enterica
Campylobacter
28 mm
20 mm
24 mm
20 mm
24 mm
33 mm
17 mm
18 mm
- a)
27 mm
27 mm
22 mm
30 mm
19 mm
22 mm
24 mm
27 mm
21 mm
30 mm
21 mm
32 mm
20 mm
28 mm
32 mm
18 mm
-
a) Resistance to fluoroquinolones is based on susceptibility results for
nalidixic acid
Escherichia coli, coagulase-negative staphylococci
and Streptococcus pyogenes. In 2001, the clinical
microbiology laboratories serving the Roskilde,
Storstroem, Ribe, Ringkoebing and Viborg counties
were using the tablet diffusion method (Neo-SensitabsÒ,
A/S Rosco) on Danish Blood Agar (Resistensplade, SSI
Diagnostika) and the breakpoints defined for this
medium by A/S Rosco. The clinical microbiology
laboratory serving North Jutland county used the same
tablets on Mueller-Hinton II agar (Becton-Dickinson,
Franklin Lakes, NJ, USA, and SSI Diagnostika) and the
breakpoints defined by the Swedish Reference Group
for Antibiotics.
In 2001, the clinical microbiology laboratories serving
the Copenhagen and Frederiksberg Municipalities,
West Zealand county and Aarhus county were using the
disk diffusion method (Oxoid, Basingstoke, UK) on 5%
horse blood Iso-Sensitest (ISA) medium (Oxoid). The
clinical microbiology laboratory serving Copenhagen
county was using the disk diffusion method (AB Biodisk,
Solna, Sweden) on 5% horse blood Antibiotic Sensitivity
Medium (PDM, AB Biodisk). All laboratories performing
the disk diffusion method used the breakpoints defined
by the Swedish Reference Group for Antibiotics
(Available from: URL: http://www.ltkronoberg.se/ext/raf/
ZONTAB/Zontab.htm).
These ten laboratories participate in national and
international quality assurance collaborations such as
the United Kingdom National External Quality
Assessment Schemes (NEQAS).
60
DANMAP 2001 - Appendix 1
Performance test
of enterococci to bacitracin, or the susceptibility of E. coli
to sulfonamide. For both tests, performed using the
Sensititre microtitre system, failures were due to
differences in reading the endpoint. However, an overall
agreement of 97.3% was considered excellent.
A performance test was carried out as in previous
years to ascertain the comparability of susceptibility
tests of the laboratories involved in the presentation of
data.
Data handling
The laboratory in the Department of Gastrointestinal
Infections and the Clinical Microbiology Laboratory at
the Statens Serum Institute as well as the Danish
Veterinary Institute and the Danish Veterinary and
Food Administration received 10 E. coli strains, 10
Enterococcus spp. and 8 Staphylococcus spp.
Data on animal isolates
A total of 1,568 antibiotic-bacterium susceptibility tests
were performed and the overall results were 2.7%
failures (Table A3. Failures were divided into
misinterpretations of test results (i.e. with similar MIC´s
found), and actual failures, i.e. > 2 fold differences in
MIC´s (or zone sizes differing completely from MICresults). Most failures were in testing the susceptibility
The results of primary examination of slaughterhouse
samples for the bacteria of interest – positive as well as
negative findings – and of the susceptibility testing were
stored in an Oracle database. The susceptibility data
were stored as continuous values (MIC) as well as
categorised as susceptible or resistant, respectively, as
defined by the relevant breakpoint. Each isolate was
identified by the bacterial species, including subtype as
applicable and by the date and place of sampling and the
species of animal. Information on the herd or flock of
origin was also recorded. All handling and evaluation of
results was carried out using PC SAS, v.8.
Table A3. Results of performance testing (correct results / number of tests performed) among
laboratories participating in DANMAP
DANMAP 2001
Antimicrobial agent
Penicillin
Ampicillin
Amox/clav
Oxacillin
Cefalothin
Ceftiofur
Erythromycin
Lincomycin
Tetracyklin
Chloramphenicol
Vancomycin
Teicoplanin
Linezolid
Synercid
Virginiamycin
Nalidixic acid
Ciprofloxacin
Neomycin
Streptomycin
Kanamycin
Apramycin
Gentamicin
Spectinomycin
Colistin
Sulfonamide
Trimethoprim
Sulfa/trim
Bacitracin
Tiamulin
Florfenicol
Avilamycin
Flavomycin
Salinomycin
Total
E.coli
S + I a)
R a)
30/30
34/36
20/20
4/4
20/20
37/40
17/20
25/25
32/32
25/25
8/8
Staphylococcus aureus
S+I
R
6/6
18/18
8/8
6/8
12/12
15/15
4/4
8/9
15/15
18/18
24/24
7/9
6/6
8/8
8/8
36/36
50/50
40/40
20/20
36/36
35/35
7/7
50/50
21/25
30/30
28/28
4/4
15/15
32/32
28/28
29/30
20/20
21/21
8/8
16/16
15/15
8/11
10/12
24/24
24/24
6/6
6/6
7/9
17/21
30/30
30/30
15/15
30/30
355/358
21/21
Total
7/9
4/4
20/20
4/4
14/15
3/3
25/25
20/20
40/40
543/552
Enterococcus spp.
S+I
R
18/18
9/9
164/168
a) S+I: susceptible and intermediate; R: resistant
18/18
5/6
6/6
8/8
8/10
7/8
12/12
8/8
21/21
21/21
14/14
21/24
8/8
8/8
8/8
2/3
2/3
1/2
259/262
82/94
123/134
1526/1568
DANMAP 2001 - Appendix 1
Data on food isolates
Results from the analysis of food samples were reported
via the Food Microbiology Database or mailed as
written data sheets. For each bacterial isolate information is available on the type of food sample, bacterial
species, date of examination of the sample, the RFCA
that collected and processed the sample, and an
identification number, which makes it possible to obtain
further information about the isolate from the Authority.
Furthermore, information about the country of origin was
recorded whenever possible. This information was
stored in a database (Microsoft Access) and the data
were combined with the susceptibility results (stored as
MIC values) in a resistance database (Microsoft Excel).
Data on human isolates
Data on Salmonella spp. and Campylobacter spp.
infections were exported from the Danish registry on
gastro-intestinal infections (Microsoft® Access)
maintained by the Department of Gastrointestinal
Infections at the Statens Serum Institut. This register
includes only one isolate per patient within a window of 6
months. Data on susceptibility testing of gastrointestinal
pathogens are stored as zone diameters (mm) in a
Microsoft® Excel database in the same department.
Using the isolate identification number, this second
database was linked to the Danish register on gastrointestinal infections and data were analysed using Epi
Info v. 6.04c.
Data on methicillin-resistant Staphylococcus aureus
(MRSA) were exported from the Danish MRSA registry
(Microsoft® Excel) maintained by the Staphylococcus
Unit at the Statens Serum Institut. Patients are only
registered in this database the first time they are
diagnosed as being infected or colonised by MRSA.
Additional information concerning the probable origin of
MRSA isolates was obtained by contacting local clinical
microbiology laboratories and from careful examination
of the patients’ discharge letters. MRSA cases were then
classified as active screening (surveillance samples to
detect nasal or skin colonisation), imported infection (in
patients who have been admitted in a foreign hospital,
refugees and children adopted from foreign countries),
infection acquired in a Danish hospital or infection
61
acquired in the Danish primary health care. Finally,
results from PFGE typing were added to the database.
Data on susceptibility testing of Streptococcus
pneumoniae isolates are stored as MICs in a Microsoft®
Access database at the Streptococcus Unit at the
Statens Serum Institut. Analysis including selection of
isolates from blood and spinal fluid samples and removal of duplicate isolates was performed using this
software.
Ten clinical microbiology laboratories provided compiled
data on resistance levels in Escherichia coli blood and
urine isolates and in coagulase-negative staphylococci
blood isolates. In nine of these laboratories, data were
extracted from the laboratory information system, i.e.
ADBakt (Autonik AB, Skoldinge, Sweden) for
Copenhagen Municipality (Hvidovre Hospital),
Copenhagen county (Herlev Hospital), West Zealand
county (Slagelse Hospital) and North Jutland county
(Ålborg Hospital), and MADS (Clinical Microbiology
Laboratory, Aarhus Kommunehospital, Aarhus, Denmark) for Aarhus county, Storstroem county (Næstved
Hospital), Ribe county (Esbjerg Hospital), Ringkoebing
county (Herning Hospital) and Viborg county (Viborg
Hospital). For Rosklide county, resistance data on E.
coli and coagulase-negative staphylococci from blood
samples were obtained from the laboratory information
system at the Statens Serum Institut, and resistance data
on E. coli from hospital urine samples from the chemical
laboratory at Roskilde County Hospital. Laboratories
were asked to provide data on the number of isolates
tested and the number found to be resistant to selected
antimicrobials. Although all laboratories were asked to
remove duplicate isolates from the same patient within a
window of 30 days, only the laboratories serving the
Copenhagen and Frederiksberg municipalities and
North Jutland county were able to comply with this rule.
Other laboratories removed duplicate isolates using a
window of 21 days (Copenhagen and West Zealand
counties) or the whole study period, i.e. one year
(Storstroem, Ribe, Ringkoebing and Viborg counties). In
the two remaining laboratories, removing duplicate
isolates would have required too much additional work
and was not performed.
62
DANMAP 2001 - Appendix 2
Appendix 2
2000
Aarestrup FM, Jensen NE, Jorsal SE, Nielsen TK. 2000.
Emergence of resistance to fluoroquinolones among
bacteria causing infections in food animals in Denmark.
Vet. Rec. 146: 76-78.
Aarestrup FM, Seyfarth AM. 2000. Effect of intervention
on the occurrence of antimicrobial resistance. Acta Vet.
Scand. 93: 99-103.
Aarestrup FM, Kruse H, Tast E, Hammerum AM, Jensen
LB. 2000. Associations between the use of antimicrobial
agents used for growth promotion and the occurrence of
resistance among Enterococcus faecium from broilers
and pigs in Denmark, Finland and Norway. Microb.
Drug resist. 6: 63-70.
Aarestrup FM, Bager F, Andersen JS. 2000. The association between the use of avilamycin for growth promotion and the occurrence of resistance among
Enterococcus faecium from broilers: an epidemiological
study and changes over time. Microb. Drug Resist. 6:
71-75.
Aarestrup FM, Agersø Y, Christensen JC, Madsen M
Jensen LB. 2000. Antimicrobial susceptibility and
presence of resistance genes in staphylococci from
poultry. Vet. Microbiol. 74: 353-364.
Aarestrup FM, Agersø Y, Gerner-Smidt P, Madsen M,
Jensen LB. 2000. Comparison of antimicrobial
resistance phenotypes and resistance genes in
Enterococcus faecalis and Enterococcus faecium from
humans in the community, broilers and pigs in Denmark.
Diagn. Microbiol. Infect. Dis. 37: 127-137.
Aarestrup FM. 2000. Characterization of glycopeptide
resistant Enterococcus faecium (GRE) from broilers
and pigs in Denmark. Genetic evidences that
persistence of GRE in pig herds is associated with coselection by resistance to macrolides. J. Clin. Microbiol.
38: 2774-2777.
Aarestrup FM, Jensen LB. 2000. Presence of variations
in ribosomal protein L16 corresponding to susceptibility
of enterococci to oligosaccharides (avilamycin and
evernimicin). Antimicrob. Agents Chemother. 44: 34253427.
Aarestrup FM. 2000. Occurrence, selection and spread
of resistance to antimicrobial agents used for growth
promotion in Denmark. APMIS 108: suppl. 101: 1-48.
Bager F, Aarestrup FM, Wegener HC. 2000. Dealing
with antimicrobial resistance – the Danish experience.
Can. J. Anim. Sci. 80: 223-228.
Bager F. 2000. DANMAP: monitoring antimicrobial
resistance in Denmark. Int. J. Antimicrob. Agents. 14:
271-274.
Baggesen DL, Sandvang D, Aarestrup FM. 2000.
Characterization of Salmonella enterica serovar
Typhimurium DT104 isolated from Denmark and
comparison with isolates from Europe and the United
States. J. Clin. Microbiol. 38: 1581-1586.
Carnevale R, Mølbak K, Bager F, Aarestrup FM. 2000.
Fluoroquinolone resistance in Salmonella: a web
discussion. Clin. Infect. Dis. 31: 128-130.
De Oliveira AP, Watts JL, Salmon SA, Aarestrup FM.
2000. Antimicrobial susceptibility of Staphylococcus
aureus isolated from bovine mastitis in Europe and the
United States. J. Dairy Sci. 83: 855-862.
Hammerum AM, Fussing V, Aarestrup FM, Wegener HC.
2000. Characterization of vancomycin-resistant and
vancomycin-susceptible Enterococcus faecium isolates
from humans, chickens and pigs by RiboPrinting and
pulsed-field gel electrophoresis. J. Antimicrob.
Chemother. 45: 677-680.
Jensen LB, Hammerum AM, Aarestrup FM. 2000.
Linkage of vatE and ermB in streptogramin resistant
Enterococcus faecium isolates from Europe [letter].
Antimicrob. Agents Chemother. 44: 2231-2232.
Kuhn I, Iversen A, Burman LG, Olsson-Liljequist B,
Franklin A, Finn M, Aarestrup FM, Seyfarth AM, Blanch
AR, Taylor H, Caplin J, Moreno MA, Dominguez L,
Mollby R. 2000. Epidemiology and ecology of
enterococci, with special reference to antibiotic resistant
strains, in animals, humans and the environment.
Example of an ongoing project within the European
research programme. Int. J. Antimicrob. Agents 14: 337342.
DANMAP 2001 - Appendix 2
Madsen L, Aarestrup FM, Olsen JE. 2000. Characterisation of streptomycin resistance determinants in
Danish isolates of Salmonella typhimurium. Vet.
Microbiol. 75: 73-82.
Monnet DL, Sørensen TL, Jepsen OB. 2000.
Implementation of a practical antibiotic policy in the
Czech Republic [letter]. Infect. Control Hosp. Epidemiol.
21: 7-8.
Monnet DL. 2000. Toward multinational antimicrobial
resistance surveillance systems in Europe. Int. J.
Antimicrob. Agents 15: 91-101.
Monnet DL. 2000. Consommation d’antibiotiques et
résistance bactérienne. Ann. Fr. Anesth. Reanim. 19:
409-417.
Monnet DL, Emborg H-D, Andersen SR, Schöller C,
Sørensen TL, Bager F. 2000. Surveillance of
antimicrobial resistance in Denmark. Eurosurveillance 5:
129-132.
Nachamkin I, Engberg J, Aarestrup FM. Diagnosis and
antimicrobial susceptibility of Campylobacter species.
In: Nachamkin I, Blaser MJ (eds.). Campylobacter, 2 nd
Edition. ASM Press, Washington DC, pp 45-66.
Sandvang D, Aarestrup FM. 2000. Characterization of
aminoglycoside resistance genes and class 1 integrons
in porcine and bovine gentamicin-resistant Escherichia
coli. Microb. Drug Resist. 6: 19-27.
Sørensen TL, Monnet DL. 2000. Control of antibiotic use
in the community: the Danish experience. Infect. Control
Hosp. Epidemiol. 21: 387-389.
Wegener HC, Frimodt-Moller N. 2000. Reducing the use
of antimicrobial agents in animals and man. J Med
Microbiol;49:111-113.
Wiuff C, Madsen M, Baggesen DL, Aarestrup FM. 2000.
Quinolone resistance among Salmonella enterica from
cattle, broilers and swine in Denmark. Microb. Drug
Resist. 6: 11-18.
2001
Aarestrup FM, Seyfarth AM, Emborg HD, Pedersen K,
Hendriksen RS, Bager F. 2001. Effect of Abolishment of
the Use of Antimicrobial Agents for Growth Promotion on
Occurrence of Antimicrobial Resistance in Fecal
Enterococci from Food Animals in Denmark. Antimicrob.
Agents Chemother. 45: 2054-2059.
63
Aarestrup FM, Engberg J. 2001. Antimicrobial
susceptibility of thermophilic Campylobacter. Vet. Res.
32: 301-310.
Arendrup M, Knudsen JD, Jensen ET, Jensen IP,
Frimodt-Moller N. Prevalence of and detection of
resistance to ampicillin and other beta-lactam antibiotics
in Haemophilus influenzae in Denmark. Scand J Infect
Dis 2001;33:266-271.
Boerlin P, Wissing A, Aarestrup FM, Frey J, Nicolet J.
2001. Antimicrobial growth promoter ban and resistance
to macrolides and vancomycin in enterococci from pigs.
J. Clin. Microbiol. 39: 4193-4195.
Engberg J, Aarestrup FM, Taylor DE, Gerner-Smidt P,
Nachamkin I. 2001. Quinolone and macrolide resistance
in Campylobacter jejuni and C. coli: resistance
mechanisms and trends in human isolates. Emerg.
Infect. Dis. 7: 24-34.
Frimodt-Møller N, Monnet DL, Sørensen TL, Konradsen
HB, Johansen HL. 2001. Increased resistance to
macrolide antibiotics. EPI - NEWS, no. 4. Available
from: URL: http://www.ssi.dk/en/epi-nyt.uk/2001/
week4.htm.
Gravesen A, Sørensen K, Aarestrup FM, Knøchel S.
2001. Spontaneous nisin-resistant Listeria
monocytogenes mutants with increased expression of a
putative penicillin-binding protein and their sensitivity to
various antibiotics. Microb. Drug Resist. 7: 127-135.
Hammerum AM, Jensen LB, Flannagan S, Clewell DB.
2001. Indication of transposition of a mobile DNAelement containing the vat(D) and the erm(B) genes in
Enterococcus faecium. Antimicrob. Agents Chemother.
45: 3223-3225.
Jensen LB, Aarestrup FM. 2001. Macrolide resistance in
Campylobacter coli of animal origin in Denmark [letter].
Antimicrob. Agents Chemother. 45: 371-372.
Jensen LB, Baloda S, Boye M, Aarestrup FM. 2001.
Antimicrobial resistance among Pseudomonas spp.
and the Bacillus cereus group isolated from Danish
agricultural soil. Environment Int. 26: 581-587.
Kariyama R, Kumon H, Hammerum AM, Aarestrup FM,
Jensen LB. 2001. Identification of a Tn1546-like (type 2)
element in vancomycin-resistant Enterococcus faecium
isolated from hospitalized patients in Japan [letter].
Antimicrob. Agents Chemother. 45: 992-993.
64
Kerrn MB, Klemmensen T, Espersen F, Frimodt-Møller
N. 2001. Control of resistance to sulphonamides. Lancet
358: 761-762.
Licht T, Hammerum AM, Jensen LB, Jacobsen BL.
2001. Effect of pheromone induction on transfer of the
Enterococcus faecalis plasmid pCF10 in intestinal
mucus ex vitro. FEMS Microbiology Letters. 405: 305309.
Mann PA, Xiong L, Mankin AS, Chau AS, Najarian DJ,
Mendrick CA, Cramer CA, Aarestrup FM, Hare RS,
Black TA, McNicholas PM. 2001. EmtA, a novel rRNA
methyltransferase conferring high-level evernimicin
resistance. Mol. Microbiol. 41: 1349-1356.
Monnet DL, Frimodt-Møller N. 2001. Antimicrobial-drug
use and methicillin-resistant Staphylococcus aureus
[letter]. Emerg. Infect. Dis. 7: 161-163.
Monnet DL, López-Lozano JM, Campillos P, Burgos A,
Yagüe A, Gonzalo N. 2001. Making sense of
antimicrobial use and resistance surveillance data:
application of ARIMA and transfer function models. Clin.
Microbiol. Infect. 7 (Suppl 5): 29-36.
Monnet DL, Sørensen TL. The patient, their doctor, the
regulator and the profit-maker: conflicts and possible
solutions. Clin Microbiol Infect 2001; 7 (Suppl 6): 27-30.
Sørensen TL, Blom M, Monnet DL, Frimodt-Møller N,
Poulsen RL, Espersen F. 2001.Transient intestinal
carriage after ingestion of antibiotic-resistant
Enterococcus faecium from chicken and pork. New
Engl. J. Med. 345: 1161-1166.
2002
Aarestrup FM, Butaye P, Witte W. 2002. Non-human
reservoirs of enterococci. In: Gilmore M (ed.).
Enterococci, 1 st Edition. ASM Press, Washington DC, (In
press).
Blom M, Sørensen TL, Espersen F, Frimodt-Møller.
2002. Validation of FLEXICULTÔ SSI-urinary kit for use
in the primary health care setting. Scand. J. Infect. Dis.
(In press).
Frimodt-Møller N. 2002. How predictive is PK/PD for
antibacterial agents? Int. J. Antimicrob. Agents 19: 333339.
DANMAP 2001 - Appendix 2
Hanon F-X, Monnet DL, Sørensen TL, Mølbak K,
Pedersen G, Schønheyder HC. 2002.
Survival of patients with bacteraemia in relation to initial
empiric antimicrobial treatment.
Scand. J. Infect. Dis. (In press).
Hasman H, Aarestrup FM. 2002. tcrB, a gene conferring
transferable copper resistance in Enterococcus
faecium: occurrence, transferability, and linkage to
macrolide and glycopeptide resistance. Antimicrob.
Agents Chemother. 46: 1410-1416.
Helms M, Vastrup P, Gerner-Smidt P, Mølbak K. 2002.
Excess Mortality Associated with Antimicrobial drugresistant Salmonella Typhimurium. Emerg. Infect. Dis. 8:
490-495.
Kerrn MB, Klemmensen T, Frimodt-Møller N, Espersen
F. 2002. Susceptibility of Danish Escherichia coli strains
isolated from urinary tract infections and bacteremia and
distribution of sul genes conferring sulphonamide
resistance. J. Antimicrob. Chemother. (In press).
Licht TR, Laugesen D, Jensen LB, Jacobsen BL. 2002
Transfer of the pheromone inducible plasmid pCF10
among Enterococcus faecalis microorganims colonizing
the intestine of mini-pigs. Applied Environ. Microbiol.
68:187-193.
López-Lozano JM, Monnet DL, Yagüe A, Campillos P,
Gonzalo N, Burgos A. 2002. Surveillance de la
résistance bactérienne et modélisation de sa relation
avec les consommations d’antibiotiques au moyen de
l’analyse des séries chronologiques.
Bull. Soc. Fr. Microbiol. (In press: http://www.sfm.asso.fr/
bull/bullgen.html).
Monnet D. 2002. Effets des interventions sur la consommation d’antibiotiques : l’exemple des pays nordiques.
In: Évin C & Huriet C (eds.). Rencontres parlementaires
“Santé Société Entreprise” : “Comment éviter la
résistance aux antibiotiques ?” Altédia Santé, Paris
(France), 2002. ISBN 2-914760-03-5.
Monnet DL. 2002. Quels sont les outils d’évaluation de
la quantité et de la qualité des prescriptions
antibiotiques à titre collectif ? Méd. Mal. Infect. (In press).
Mølbak K, Gerner-Smidt P, Wegener HC. 2002.
Increasing quinolone resistance in Salmonella
enterica serotype Enteritidis. Emerg. Infect. Dis. 8:
514-515.
DANMAP 2001 - Appendix 2
Sørensen TL, Monnet DL, Frimodt-Møller N. 2002.
DANMAP 2000. EPI - NEWS, no. 6. Available from:
http://www.ssi.dk/en/epi-nyt.uk/2002/6.pdf
Sørensen TL, Wegener HC, Frimodt-Møller N. 2002.
Resistant bacteria in retail meats and antimicrobial use
in animals [letter]. N. Engl. J. Med. 346: 779.
65
66
DANMAP 2001 - Appendix 3
Appendix 3
Results for food isolates from 2000
For technical reasons data on resistance in bacteria
from food were not included in the report from 2000.
Instead they are presented here. Please refer to the
DANMAP 2000 (available on http://www.vetinst.dk) for
the corresponding data from food animals and humans
in Denmark 2000.
Table A4. Occurrence of
resistance among Salmonella Enteritidis from broiler
meat, Denmark 2000
(n=12) (all isolates from DANMAP 2001
Table A5. Occurrence of resistance
among Salmonella Typhimurium
from pork, Denmark 2000 (n=18)
(danish pork 4 isolates; imported
pork 14 isolates).
DANMAP 2001
Compound
Compound
% Resistant
[95% Confidence interval]
Tetracycline
Chloramphenicol
Florfenicol
Ampicillin
Ceftiofur
Sulfonamide
Trimethoprim
Apramycin
Gentamicin
Neomycin
Spectinomycin
Streptomycin
Ciprofloxacin
Nalidixic acid
Colistin
0
0
0
8
0
0
0
0
0
0
0
8
0
33
0
[0.0-26.5]
[0.0-26.5]
[0.0-26.5]
[0.2-38.5]
[0.0-26.5]
[0.0-26.5]
[0.0-26.5]
[0.0-26.5]
[0.0-26.5]
[0.0-26.5]
[0.0-26.5]
[0.2-38.5]
[0.0-26.5]
[9.9-65.1]
[0.0-26.5]
% Resistant
[95% Confidence interval]
Tetracycline
Chloramphenicol
Florfenicol
Ampicillin
Ceftiofur
Sulfonamide
Trimethoprim
Apramycin
Gentamicin
Neomycin
Spectinomycin
Streptomycin
Ciprofloxacin
Nalidixic acid
Colistin
72
44
44
50
0
72
33
0
0
6
50
50
0
0
0
[46.5-90.3]
[21.5-69.2]
[21.5-69.2]
[26.0-74.0]
[0.0-18.5]
[46.5-90.3]
[13.3-59.0]
[0.0-18.5]
[0.0-18.5]
[0.1-27.3]
[26.0-74.0]
[26.0-74.0]
[0.0-18.5]
[0.0-18.5]
[0.0-18.5]
Table A6. Distribution of MICS and occurrence of resistance among Campylobacter jejuni from
broiler meat (n=105) Denmark, 2000
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
% Resistant
[95% Confidence interval]
5
1
<=0.03 0.06 0.12 0.25
[1.6-10.8]
[0.0-5.2]
0.5
Distribution (%) of MICs
1
2
4
8 16
81.9 9.5 1.0
0.0 62.9 19.0
1.0 1.9
7.6 9.5
32
Erythromycin
2
[0.2-6.7]
29.5 48.6 17.1
2.9
1.9
Gentamicin
Streptomycin
0
9
[0.0-3.5]
[4.0-15.6]
91.4
1.0
1.0 7.6 2.9
5.7
Ciprofloxacin
Nalidixic acid
10
10
[4.7-16.8]
[4.7-16.8]
2.9
3.8 21.9 46.7 14.3
7.6
78.1
4.8
1.0
1.0 1.0 7.6
10.5 19.0 39.0 7.6 6.7
64 128 256 512 >512
4.8 a)
1.0
7.6 5.7
3.8
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. MICs equal to or lower than the lowest concentration tested
are given as the lowest concentration
DANMAP 2001 - Appendix 3
67
Table A7. Distribution of MICs and occurrence of resistance among Enterococcus faecium from turkey
meat (n=10), broiler meat (n=36), beef (n=21) and pork (n=12), Denmark, 2000
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Penicillin
Erythromycin
Gentamicin
Kanamycin
Streptomycin
Vancomycin
Virginiamycin
Quinupristin/dalfopristin
Avilamycin
Bacitracin
Nitrofurantoin
Salinomycin
Food type
% Resistant
[95% Confidence interval]
<=0.5
1
2
Turkey meat
Broiler meat
50
50
[18.7-81.3]
[32.9-67.1]
40.0 10.0
50.0
Beef
Pork
19
25
[5.5-41.9]
[5.5-57.2]
71.4
75.0
4.8
4
8
Distribution (%) of MICs
16
32
64 128 256
2.8
4.8
4.8
8.3
Turkey meat
0
[0.0-30.9]
50.0 30.0
20.0
Broiler meat
Beef
3
0
[0.1-14.5]
[0.0-16.1]
58.3 13.9 22.2
57.1 14.3 23.8
2.8
4.8
Pork
Turkey meat
0
0
[0.0-26.5]
[0.0-30.9]
41.7 25.0 33.3
100
Broiler meat
0
[0.0-9.7]
91.7
Beef
Pork
0
0
[0.0-16.1]
[0.0-26.5]
81.0 19.0
58.3 41.7
Turkey meat
Broiler meat
20
31
[2.5-55.6]
[16.3-48.1]
60.0 20.0
55.6 8.3
5.6
Beef
Pork
10
8
[1.2-30.4]
[0.2-38.5]
57.1
58.3
23.8
33.3
512 1024 2048 >2048
50 a)
47.2
14.3
16.7
2.8
8.3
9.5
10.0
8.3
5.6
4.8
8.3
10.0
2.8
8.3
5.6
4.8
Turkey meat
20
[2.5-55.6]
40.0 20.0 20.0
Broiler meat
Beef
28
24
[14.2-45.2]
[8.2-47.2]
50.0 16.7 5.6
33.3 19.0 23.8
20.0
Pork
Turkey meat
17
0
[2.1-48.4]
[0.0-30.9]
41.7 33.3
Broiler meat
0
[0.0-9.7]
97.2
Beef
Pork
0
0
[0.0-16.1]
[0.0-26.5]
100
100
Turkey meat
Broiler meat
0
11
[0.0-30.9]
[3.1-26.1]
70.0 30.0
52.8 30.6
2.8
2.8
Beef
Pork
10
0
[1.2-30.4]
[0.0-26.5]
76.2
66.7
9.5
16.7
16.7
Turkey meat
10
[0.3-44.5]
70.0
10.0
10.0
Broiler meat
Beef
14
0
[4.7-29.5]
[0.0-16.1]
86.1
66.7
33.3
Pork
Turkey meat
0
0
[0.0-26.5]
[0.0-30.9]
5.6
22.2
19.0
4.8
8.3
16.7
100
66.7
2.8
4.8
11.1
9.5
10.0
13.9
8.3
16.7
8.3
100
Broiler meat
3
[0.1-14.5]
97.2
Beef
Pork
0
0
[0.0-16.1]
[0.0-26.5]
95.2
91.7
2.8
Turkey meat
Broiler meat
10
14
[0.3-44.5]
[4.7-29.5]
10.0
38.9
60.0 20.0
30.6 11.1
5.6
Beef
Pork
0
8
[0.0-16.1]
[0.2-38.5]
42.9
66.7
14.3 38.1
16.7
4.8
8.3
Turkey meat
10
[0.3-44.5]
Broiler meat
Beef
14
0
[4.7-29.5]
[0.0-16.1]
33.3
28.6
36.1 16.7
33.3 38.1
Pork
Turkey meat
8
20
[0.2-38.5]
[2.5-55.6]
25.0
41.7 25.0 8.3
60.0 10.0 10.0
Broiler meat
Beef
22
14
[10.1-39.2]
[3.1-36.3]
27.8 27.8 19.4
42.9 42.9
33.3 41.7 25.0
4.8
8.3
40.0 50.0
10.0
13.9
8.3
10.0
8.3
2.8
2.8
20.0
2.8
2.8
9.5
19.4
4.8
Pork
0
[0.0-26.5]
Turkey meat
Broiler meat
30
67
[6.7-65.3]
[49.0-81.4]
30.0 30.0 10.0
19.4 2.8 2.8
8.3
30.0
66.7
Beef
Pork
24
17
[8.2-47.2]
[2.1-48.4]
23.8
16.7
38.1 14.3
50.0 8.3
9.5
8.3
Turkey meat
20
[2.5-55.6]
80.0 20.0
Broiler meat
Beef
6
0
[0.1-18.7]
[0.0-16.1]
94.4
100
Pork
Turkey meat
0
0
[0.0-26.5]
[0.0-30.9]
90.0 10.0
Broiler meat
Beef
Pork
0
0
0
[0.0-9.7]
[0.0-16.1]
[0.0-26.5]
47.2 13.9 36.1
100
91.7 8.3
4.8
9.5
16.7
5.6
100
2.8
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
68
DANMAP 2001 - Appendix 3
Table A8. Distribution of MICs and occurrence of resistance among Enterococcus faecalis from turkey
meat (n=17), broiler meat (n=33), beef (n=18) and pork (n=29), Denmark, 2000
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Penicillin
Erythromycin
Gentamicin
Kanamycin
Streptomycin
Vancomycin
Avilamycin
Bacitracin
Flavomycin
Nitrofurantoin
Salinomycin
food type
% Resistant
[95% Confidence interval]
Distribution (%) of MICs
<=0.5
1
2
5.9
Turkey meat
76
[50.1-93.2]
17.6
Broiler meat
42
[25.5-60.8]
57.6
Beef
17
[3.6-41.4]
77.8
86.2
4
8
16
32
64
128 256 512 1024 2048 >2048
76.5 a)
12.1
5.6
30.3
16.7
Pork
14
[3.9-31.7]
Turkey meat
0
[0.0-19.5]
11.8 29.4 58.8
13.8
Broiler meat
0
[0.0-10.6]
30.3 21.2 48.5
Beef
0
[0.0-18.5]
22.2 77.8
Pork
3
[0.1-17.8]
20.7 24.1 51.7
Turkey meat
0
[0.0-19.5]
58.8 41.2
Broiler meat
0
[0.0-10.6]
66.7 33.3
Beef
0
[0.0-18.5]
77.8 22.2
Pork
0
[0.0-11.9]
69.0 31.0
Turkey meat
0
[0.0-19.5]
64.7 35.3
Broiler meat
0
[0.0-10.6]
87.9 12.1
Beef
6
[0.1-27.3]
77.8 16.7
Pork
0
[0.0-11.9]
79.3 20.7
Turkey meat
29
[10.3-56.0]
41.2
23.5
5.9
Broiler meat
21
[9.0-38.9]
57.6
18.2
3.0
Beef
22
[6.4-47.6]
61.1
16.7
22.2
62.1
34.5
3.4
3.4
5.6
29.4
6.1
6.1
9.1
Pork
3
[0.1-17.8]
Turkey meat
0
[0.0-19.5]
100
Broiler meat
0
[0.0-10.6]
100
Beef
0
[0.0-18.5]
100
Pork
3
[0.1-17.8]
96.6
Turkey meat
6
[0.1-28.7]
94.1
Broiler meat
3
[0.1-15.8]
93.9 3.0
3.0
Beef
6
[0.1-27.3]
94.4
5.6
3.4
5.9
Pork
3
[0.1-17.8]
96.6
3.4
Turkey meat
18
[3.8-43.4]
82.4
17.6
Broiler meat
12
[3.4-28.2]
87.9
Beef
17
[3.6-41.4]
83.3
Pork
0
[0.0-11.9]
Turkey meat
0
[0.0-19.5]
3.0
9.1
16.7
100
52.9
47.1
Broiler meat
0
[0.0-10.6]
72.7
27.3
Beef
0
[0.0-18.5]
61.1
38.9
Pork
0
[0.0-11.9]
58.6
41.4
Turkey meat
6
[0.1-28.7]
17.6
64.7 11.8
Broiler meat
0
[0.0-10.6]
36.4
63.6
Beef
0
[0.0-18.5]
27.8
61.1
5.6
Pork
0
[0.0-11.9]
31.0
62.1
6.9
5.9
5.6
Turkey meat
41
[18.4-67.1]
17.6 29.4
Broiler meat
24
[11.1-42.3]
42.4 12.1 21.2
Beef
6
[0.1-27.3]
50.0 11.1 22.2
Pork
0
[0.0-11.9]
Turkey meat
0
[0.0-19.5]
17.6
17.6
52.9
5.9
5.9
Broiler meat
0
[0.0-10.6]
24.2
12.1
54.5
6.1
3.0
Beef
0
[0.0-18.5]
27.8
22.2
44.4
5.6
6.9
10.3
75.9
6.9
5.9
5.9
11.1
5.9
35.3
3.0
21.2
5.6
58.6 24.1 17.2
Pork
0
[0.0-11.9]
Turkey meat
0
[0.0-19.5]
100
Broiler meat
0
[0.0-10.6]
100
Beef
0
[0.0-18.5]
100
Pork
0
[0.0-11.9]
100
Turkey meat
0
[0.0-19.5]
88.2
5.9
Broiler meat
0
[0.0-10.6]
90.9
9.1
Beef
0
[0.0-18.5]
100
Pork
0
[0.0-11.9]
100
5.9
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration
DANMAP 2001 - Appendix 3
69
Table A9. Susceptibility and occurrence of resistance among Escherichia coli from turkey meat (n=51)
broiler meat (n=79), beef (n=81) and pork (n=62), Denmark, 2000
DANMAP 2001
Compound
Tetracycline
Chloramphenicol
Florfenicol
Ampicillin
Ceftiofur
Sulfonamide
Trimethoprim
Apramycin
Gentamicin
Neomycin
Spectinomycin
Streptomycin
Ciprofloxacin
Nalidixic acid
Colistin
Food type
% Resistant
[95% Confidence interval]
Distribution (%) of MICs
<=0.03 0.06 0.12 0.25
0.5
1
2
Turkey meat
55
[40.3-68.9]
45.1
Broiler meat
37
[26.1-48.3]
60.8
Beef
Pork
7
18
[2.8-15.4]
[9.2-29.5]
92.6
80.6
4
1.3
8
1.3
16
32
64
2.0
3.9
49.0 a)
6.3
7.6
22.8
2.5
8.1
4.9
9.7
1.6
Turkey meat
6
[1.2-16.2]
37.3
41.2
13.7
Broiler meat
5
[1.4-12.5]
39.2
41.8
13.9
Beef
1
[0.0-6.7]
11.1
33.3
54.3
Pork
Turkey meat
0
0
[0.0-5.8]
[0.0-7.0]
30.6
49.0
29.0
41.2
40.3
9.8
2.0
2.5
1.2
0
[0.0-4.6]
51.9
38.0
10.1
Beef
0
[0.0-4.5]
13.6
45.7
40.7
Pork
Turkey meat
0
27
[0.0-5.8]
[15.9-41.7]
35.5
41.2 29.4
35.5
2.0
29.0
Broiler meat
20
[12.0-30.8]
39.2 32.9
7.6
20.3
Beef
4
[0.8-10.4]
13.6 59.3
23.5
3.7
Pork
Turkey meat
8
0
[2.7-17.8]
[0.0-7.0]
30.6 43.5
17.7
8.1
100
Broiler meat
0
[0.0-4.6]
98.7
Beef
0
[0.0-4.5]
100
98.4
Pork
0
[0.0-5.8]
35
30
[22.4-49.9]
[20.5-41.8]
27.5
1.3
1.6
64.7
68.4
9
[3.5-17.0]
88.9
2.5
Pork
15
[6.9-25.8]
82.3
1.6
Turkey meat
Broiler meat
24
18
[12.8-37.5]
[10.0-27.9]
76.5
82.3
Beef
6
[2.0-13.8]
93.8
Pork
8
[2.7-17.8]
90.3
1.6
Turkey meat
Broiler meat
0
0
[0.0-7.0]
[0.0-4.6]
98.0
97.5
2.0
2.5
Beef
0
[0.0-4.5]
95.1
4.9
Pork
0
[0.0-5.8]
90.3
9.7
Turkey meat
0
[0.0-7.0]
98.0
2.0
Broiler meat
Beef
3
0
[0.3-8.8]
[0.0-4.5]
96.2
98.8
1.3
1.2
98.4
Pork
0
[0.0-5.8]
Turkey meat
2
[0.0-10.4]
98.0
Broiler meat
Beef
6
4
[2.1-14.2]
[0.8-10.4]
92.4
96.3
98.4
35.3
30.4
1.3
Beef
8.6
1.6
14.5
23.5
17.7
6.2
8.1
2.5
1.6
2.0
1.3
2.5
2.5
1.2
1.3
2.5
Pork
0
[0.0-5.8]
Turkey meat
2
[0.0-10.4]
3.9
43.1 33.3
9.8
7.8
Broiler meat
Beef
11
4
[5.3-20.5]
[0.8-10.4]
2.5
1.2
51.9 29.1
19.8 66.7
3.8
7.4
1.3
1.2
1.6
2.0
7.6
2.5
Pork
5
[1.0-13.5]
30.6 51.6
9.7
3.2
Turkey meat
27
[15.9-41.7]
43.1
21.6
7.8
2.0
5.9
19.6
Broiler meat
Beef
27
6
[17.3-37.7]
[2.0-13.8]
55.7
33.3
16.5
55.6
1.3
4.9
2.5
1.2
6.3
17.7
4.9
Pork
13
[5.7-23.9]
38.7
41.9
6.5
4.8
8.1
Turkey meat
0
[0.0-7.0]
Broiler meat
4
1.3
2.5
Beef
0
Pork
Turkey meat
92.2
2.0
3.9
[0.8-10.7]
83.5
2.5
7.6
[0.0-4.5]
98.8
0
6
[0.0-5.8]
[1.2-16.2]
100
Broiler meat
14
[7.2-23.6]
83.5
Beef
1
[0.0-6.7]
96.3
Pork
Turkey meat
0
0
[0.0-5.8]
[0.0-7.0]
100
100
Broiler meat
0
[0.0-4.6]
100
Beef
Pork
0
0
[0.0-4.5]
[0.0-5.8]
100
100
3.8
1.2
4.8
2.0
1.3
1.3
>512
5.9
2.5
Broiler meat
Turkey meat
Broiler meat
128 256 512
1.2
94.1
3.9
2.5
2.5
3.8
2.0
5.1
5.1
1.2
Lines indicate breakpoints for resistance
a) The white fields denote range of dilutions tested for each antimicrobial. Values above the range denote MIC values greater than the highest
concentration in the range. MICs equal to or lower than the lowest concentration tested are given as the lowest concentration